chapter 1&2 revised

see attachment

Topic: U.S healthcare system: its future

1- Make revision on chapter 1 and chapter 2 based off professor’s comments.

2- For Chapter 1, you need to find another research question that can be tested with data sets.

You also need one research hypothesis. Please make correction accordingly for chapter 3 that is about data sets.

Chapter 2

Literature Review

2.1 Overview

The debate about the efficiency of U.S. healthcare systems has infiltrated literature and the public sphere. An efficient healthcare system ensures continuity, quality, affordability, access to timely care, and uses of evidence-based practices to inform treatment decisions. High healthcare costs and spending characterize healthcare in the U.S. The increased healthcare costs and spending particularly drive the increased debate about the need to reform the Affordable Care Act (ACA). Millions of Americans incur thousands of dollars in healthcare costs, paying for healthcare premiums. A report by AHRQ highlights that the total health expenditures in the U.S. summed up to approximately $3trillion in 2017. While this figure illuminates increased utilization of health services, inequalities persist in the U.S. healthcare system, especially on people of color and other marginalized communities. Institutional inequalities create gaps in access to health services and resources, health insurance coverage, and poor health outcomes among these marginalized groups. Although primary care is often used to reduce health inequalities in healthcare systems, inequalities also exist in the provision of primary care services in the U.S. health care system. This literature review explores various sources and theoretical framework that explain inequalities in the U.S. healthcare system and the provision of primary care services among marginalized communities. 

2.2 Inequalities in The U.S. Healthcare System

According to Braveman (2012), health inequalities refers to gaps in healthcare created by differences in social class. Throughout history, health inequalities in the U.S have been defined along with race and ethnicity. Widening health disparities in the U.S. are well documented with marginalized groups, and low-income families are having the worst health outcomes. Despite scant literature about the socioeconomic inequalities in health, recent data about inequalities in the U.S. healthcare systems depict those disparities by economic class or ethnicity exist. Dickman, Himmelstein, and Woolhandler (2017) attribute widening health disparities in America to the increasing economic inequality in the U.S. Income disparity between the rich and low-income families increase health disparities wherein the prevalence of diseases is inversely proportional to income earned by low-income earners. Most wealth in the country is accumulated by the rich, while the low-income earners and marginalized groups compete for limited resources. Over 1.6 million families in America survive on incomes of below$2 per person every day, extreme poverty. 

Dickson, Himmelstein, and Woolhandler (2017) further explain that instead of reducing the effects of economic inequality on health, the financing systems in the U.S healthcare system perpetuate these effects through high health costs and spending. In affirmation, Blazheski and Karp (2018) explain that inefficient regulation policies in the U.S. healthcare system increase healthcare spending. The report highlights that 18% of the country’s GDP was spent on healthcare, which accounted for $3.3 trillion in 2016.  Despite high spending on healthcare, the U.S has adverse health outcomes on metrics such as life expectancy and infant mortality rates. A study by Van II (2018) agrees with these findings by depicting that most patients also spend billions in paying for medical bills and health premiums. 

Increased household spending on healthcare leads to income inequality and subsequent disparities in utilization of health services. Even after the implementation of ACA, Americans pay heavily for insurance premiums relative to the income differences between the rich and low-income earners. Dickson, Himmelstein, and Woolhandler (2017) suggest that high health costs render Americans to high medical bills, bankruptcy, and eventually push them to extreme poverty. The high healthcare costs do not correspond with the increases in demand or quality of care. While health insurance should aim at ensuring the provision of affordable care, a study by Schmid and Himmler (2015) depicts that both the insured and uninsured persons incur high medical costs, annulling the practicability of ACA.

On the contrary, Van II (2018) postulates that health insurance coverage has significantly reduced medical bills. ACA particularly reduced the number of people affected by high medical bills by 1.5 million people from 2010 to 2017. A report by the Centers for Disease Control Prevention (CDCP) supports this idea by depicting a reduction in the percentage of American overburdened by medical bills between 2011 and 2016 (Cohen and Zammitti, 2016). Health disparities in the U.S result mainly from reduced health coverage and inadequate health insurance among marginalized groups and low-income families. Minority groups in America have problems accessing high-quality care than Whites due to their low median income. Numerous studies show that despite expanded coverage by Medicare and Medicaid programs to accommodate the elderly and low-income families, disparities in access to care still exist (Dickman, Himmelstein, and Woolhandler (2017), Taylor (2019). Just like Dickman, Himmelstein, and Woolhandler (2017), Taylor (2019) suggests that access to affordable healthcare is a challenge to most marginalized groups. 

Under coverage is the major issues hindering marginalized groups from accessing health services like whites. For instance, 5.4 % of whites and 9.7% African-Americans were uninsured in America in 2018 (Taylor, 2019). Most African Americans use private health insurance, while others rely on Medicaid and other types of public health insurance. Taylor (2019) argues that underinsurance among marginalized groups prompts them to spend $8,200 annually on health care premiums and incur direct costs for services such as prescription drugs. This data is congruent to findings by Dickman et al. (2017) that uninsured minority groups suffering from diabetes spend $1446 direct costs for medical services annually and most of them do not have access to primary care providers. Accordingly, low-income and uninsured Americans suffering from chronic illnesses are less likely than the insured and high-income earners to go through successful medical appointments.

While most of these authors attribute inequality in access to health services top widening health disparities in the U.S, a report by Blair et al. (2011) shows that minorities still receive low-quality care due to implied bias from care providers. Although the extent of this bias varies, the presence of implicit bias in the U.S healthcare system is consistent throughout the study, suggesting that care providers have an inherent prejudice towards minorities in society. However, the authors did not point out the impact of care providers’ implicit bias on minorities’ health care outcomes. Instead, the authors noted that other studies have shown a positive correlation between care providers bias and perceived health outcomes whereby racial ideology is used to inform treatment plans.

Similarly, statistics by the American College of Physicians (2010) showed that minorities have less access to healthcare services and receive poorer quality of care than whites. Based on the literature presented, it is apparent that inequalities in the U.S. healthcare system are largely due to inequality in access to healthcare services and provision of low-quality among minority groups. The disparities in healthcare discussed in this section are by no means comprehensive since other factors could be considered, such as language and religious barriers. Nevertheless, there is a need to recognize the problems faced by minorities in accessing healthcare and receiving low-quality care.

2.3 Primary Care and The U.S. Health System

Despite high health costs and spending in the U.S. healthcare system, the country still has adverse health outcomes. One of the major factors contributing to these outcomes is reduced emphasis on primary care within the health system (Weidner and Davis, 2018). Currently, there is a gap in the utilization of primary care services and the supply of the number of care providers needed to deliver primary care to the entire American population. This gap makes it imperative to understand various issues such as the extent to which medical students enroll to study primary care, the supply of care providers among marginalized communities and inequalities in the delivery of primary care services.

Medical students’ choice of specialty is well documented. Weidner and Davis (2018) argued that the process of medical education hinder medical students from choosing primary care. Peterson et al. (2018) support this argument by noting that American medical education underlies on a hidden curriculum that favor specialist over generalist, which discourage students from pursuing primary care. Most students in the study associated primary care with low-prestige as cited by Lahad at et al. (2018). Even these students showed interest in primary care, Weissman et al. (2018) discovered that they were inclined to pursue a primary care specialty in urban areas and disinterested in marginalized regions. The cornerstone of primary is based partly on reducing health inequalities and social factors that hindered people from accessing care. The gap in reimbursement for primary care providers and high students’ debt discourage students from pursuing primary care specialty (Kruse, 2013). Primary care is the lowest paid medical professionals in the United States. Primary care providers include family and general practitioners, internists, and pediatricians. States in the United States that have a high number of primary healthcare providers recorded positive health outcomes such as reduced mortality rates.

On the contrary, a study by van Dorn, Cooney, and Sabin (2020) reported that both primary care and income inequality influence health outcomes. These findings suggest that the reduced supply of primary care providers in the U.S produce adverse health outcomes among the affected populations. Availability of primary care providers determined the number of persons that accessed primary care services.

A report by Shi et al. (2017) indicated that the percentage of the American population with access to primary care provider stagnated between 1996 and 2015 from 76.8% to 76.4% respectively. This problem is compounded by the fact that a high proportion of American population has been enrolled into high-deductible health plans (HDHPS) from 15% in 2007 to 43% in 2017 (Shi et al., 2017). This shift has made it hard for minorities and low-income families to access primary care services. In 2018, the average HDHP deductible for one person ranged at $1500 and $2800 for a household. The research concluded that most Americans, especially low-income families, could not afford primary care even those with health insurance. This literature review highlights the need for increased emphasis on primary healthcare to reform the education system for medical students, improve the supply of primary care providers, and enhance access to primary care, especially by marginalized groups.

2.4 Inequality in the U.S Primary Care.

Primary health care focuses on providing care to individuals by taking care services and medical interventions near to that population. An evaluation study for value-based care by Ma et al. (2019) described that provision of primary care is determined by practices that incorporate individuals social, environmental, political, cultural, and epidemiological aspects of a community. The author emphasized that access is integral to the supply and distribution of healthcare services and play a vital role in ensuring equality in health systems. 

Minority groups remain vulnerable and deficient in terms of accessing and being included in primary healthcare programs. As such, Ma et al. (2019) concluded that access to primary healthcare by minorities is constrained by various factors such as lack of health insurance, documentation and length of stay in America. This conclusion aligns with findings by Heath (2019), which showed that health inequalities existed along racial lines whereby adult patients from minority groups were less likely to consult a primary care provider than their white peers. Particularly, patients residing in the South were less likely to have primary care providers than patients in other parts of the United States. The U.S. Census Bureau Annual Estimates (2019) deduced that the shortage of care providers in marginalized regions produce racial and disparities in access to primary care. 

Minority populations affected by these inequalities between 2013 to 2015 were Hispanic and black adults and non-white adults. These disparities are explained by lack of access to primary care services. Primary care institutions and physicians are concentrated in urban areas (Douthit et al., 2015). However, this abundance in urban areas does not increase the supply of primary care providers in rural areas inhabited by low-income families and minority populations. As a result, both the urban poor and marginalized groups report difficulties in obtaining primary care services. Inadequate primary care services among these people are attributed to various disincentives for primary care providers such as increased reliance on Medicaid, poverty, few people with disposable income, and high rates of noncompliance in treatment interventions.

Medicaid also undervalues physicians by paying them low incomes and charging them high administrative costs, which discourage them from serving in marginalized communities. Nevertheless, de Andrade et al. (2015) agrees that reduced access to primary care services for marginalized communities implies that minorities living in extreme poverty are less likely to receive care frequently than Whites and tend to rely heavily on hospital-based care. This preference for hospital-based care is perpetuated by residential segregation and location of hospitals, and financial barriers such as payment for insurance premiums. This problem is recognized by Buerhaus (2018), who highlighted the need for affordable primary services in marginalized communities. 

2.5 Theoretical Frameworks

Various theoretical frameworks have been adopted to explain inequalities in healthcare systems. Current theories focus on the social determinants of health to explain health disparities. The social production of the political economy of health framework suggests that the relationship between economic inequality and health must address the structural cause of inequalities (Arcaya, Arcaya, and Subramanian, 2015). This implies that the effect of economic inequality on health mirrors the lack of resources and wealth accumulated across a plethora of community infrastructure. Economic and political powers influence the amount of wealth accumulated by individuals and shape the nature of public health (Watt and Sheiham, 2012). In this regard, economic inequality reflects the material conditions that affect population health. Various researchers support this aspect and emphasize that health inequalities result from differences in the accumulation of material resources. Accordingly, people with resources such as health knowledge, social connections, wealth, and power can avoid health risks by seeking medical services and adopt prevention measures available at a given time and place. 

Another most used theoretical framework is a life course perspective. Researchers have used this model to explain how various social determinants of health operate at every level of human development to influence health (Corna, 2013; Arcaya, Arcaya, and Subramanian, 2015). 

Particularly, research focus on the accumulation of risk perspective by suggesting that factors that promote good health are accumulated gradually throughout a person’s life course. In this regard, a person’s childhood social class experiences can be accumulated and influence later health life. For instance, exposure to educational activities during childhood and early adulthood, influence a person’s income level during adulthood, and health in adulthood. Jones et al. (2019) criticize this theory and suggest that the theory should integrate both biological and social transmission of health and risks across generations.

On the contrary, Brotman, Ferrer, and Koehn (2020) used this theory to develop an understanding of health disparities across countries and populations. The author suggests that health inequalities lie in socially-structured exposures at different stages of a person’s life. Low-income in adult life has huge health impacts on a person who grew up in a low-income family by amplifying the health effects of extreme poverty. Brown (2018) argued along this line and notes that early life conditions among marginalized groups are vital in explaining current health inequalities. Disparities in access to health services at early life generate stress and health behaviors which influence the health status of marginalized groups in future. 

References

American College of Physicians. Racial and Ethnic Disparities in Health Care, Updated 2010. Philadelphia: American College of Physicians; 2010: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)

America’s Health Rankings analysis of Special data request for information on active state licensed physicians provided by Redi-Data, Inc., Sept. 23, 2019; U.S. Census Bureau Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2018, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.

Arcaya, M. C., Arcaya, A. L., & Subramanian, S. V. (2015). Inequalities in health: definitions, concepts, and theories. Global health action, 8(1), 27106.

Bates, D. W. (2010). Primary care and the US health care system: what needs to change? Journal of general internal medicine, 25(10), 998-999.

Blair, I. V., Steiner, J. F., & Havranek, E. P. (2011). Unconscious (implicit) bias and health disparities: where do we go from here? The Permanente Journal, 15(2), 71.

Blazheski, F., & Karp, N. (2018). Got symptoms? High US healthcare spending and its long-term impact on economic growth. US Economic Watch, 10-20.

Braveman, P. (2012). Health inequalities by class and race in the US: What can we learn from the patterns? Social science & medicine, 74(5), 665-667.

Brown, T. H. (2018). Racial stratification, immigration, and health inequality: A life course-intersectional approach. Social Forces, 96(4), 1507-1540.

Brotman, S., Ferrer, I., & Koehn, S. (2020). Situating the life story narratives of aging immigrants within a structural context: the intersectional life course perspective as research praxis. Qualitative Research, 20(4), 465-484.

Buerhaus, P. (2018). Nurse practitioners: A solution to America’s primary care crisis. American Enterprise Institute, 1-30.

Cohen, R. A., & Zammitti, E. P. (2016). Problems paying medical bills among persons under age 65: early release of estimates from the National Health Interview Survey 2011-June 2016. In Statistics NCfH.

Corna, L. M. (2013). A life course perspective on socioeconomic inequalities in health: a critical review of conceptual frameworks. Advances in life course research, 18(2), 150-159.

de Andrade, L. O. M., Pellegrini Filho, A., Solar, O., Rígoli, F., de Salazar, L. M., Serrate, P. C. F., … & Atun, R. (2015). Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. The Lancet, 385(9975), 1343-1351.

Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to health care access in the rural USA. Public health, 129(6), 611-620.

Heath, S. (2019). Primary Care Access Drops 2%, Prompting Calls for Policy Change.

https://patientengagementhit.com/news/primary-care-access-drops-2-prompting-calls-for-policy-change

Jones, N. L., Gilman, S. E., Cheng, T. L., Drury, S. S., Hill, C. V., & Geronimus, A. T. (2019). Life course approaches to the causes of health disparities. American journal of public health, 109(S1), S48-S55.

Kruse, J. (2013). Income ratio and medical student specialty choice: the primary importance of the ratio of mean primary care physician income to mean consulting specialist income. Family medicine, 45(4), 281.

Lahad, A., Bazemore, A., Petek, D., Phillips, W. R., & Merenstein, D. (2018). How can we change medical students’ perceptions of a career in family medicine? Marketing or substance? Israel journal of health policy research, 7(1), 52.

Ma, Q., Sylwestrzak, G., Oza, M., Garneau, L., & DeVries, A. R. (2019). Evaluation of value-based insurance design for primary care. Am J Manag Care, 25(5), 221-227.

Peterson, L. E., Fang, B., Puffer, J. C., & Bazemore, A. W. (2018). Wide gap between preparation and scope of practice of early career family physicians. The Journal of the American Board of Family Medicine, 31(2), 181-182.

Shi, Y., Yi, H., Zhou, H., Zhou, C., Xue, H., Rozelle, S., … & Sylvia, S. (2017). The quality of primary care and correlates among grassroots providers in rural China: a cross-sectional standardised patient study. The Lancet, 390, S16.

Schmid, A. and Himmler, S. (2015), Netzwerkmedizin: Impulse für Deutschland aus den USA, Stiftung Münch.

Taylor, J. (2019). Racism, Inequality, and Health Care for African Americans.

https://tcf.org/content/report/racism-inequality-health-care-african-americans/?session=1&session=1&session=1

van Dorn, A., Cooney, R. E., & Sabin, M. L. (2020). COVID-19 exacerbating inequalities in the US. Lancet (London, England), 395(10232), 1243.

Watt, R. G., & Sheiham, A. (2012). Integrating the common risk factor approach into a social determinants framework. Community dentistry and oral epidemiology, 40(4), 289-296.

Weidner, A., & Davis, A. (2018). Influencing medical student choice of primary care worldwide: international application of the four pillars for primary care physician workforce. Israel journal of health policy research, 7(1), 1-4.

Weissman, C., Zisk-Rony, R. Y., Avidan, A., Elchalal, U., & Tandeter, H. (2018). Challenges to the Israeli healthcare system: attracting medical students to primary care and to the periphery. Israel journal of health policy research, 7(1), 28.

II, V. (2018). The American Health-Care System Increases Income Inequality.

https://www.theatlantic.com/politics/archive/2018/01/health-care-income-inequality-premiums-deductibles-costs/550997/

Chapter 1

Introduction

Introduction

The U.S. healthcare system comprises of a complex organization focused on providing coordinated, affordable, efficient and high-quality care. Despite the implementation of health policies such as the Affordable Care Act (ACA) to provide cost-effective care, reduce the uninsured rate and enhance access to care, the healthcare cost and spending in the United States are still high. A high percentage of the country’s Gross Domestic Product (GDP) is spent on healthcare, higher than the amount spent by other countries in the Organization for Economic Cooperation and Development (OECD). According to Keehan et al. (2016), healthcare spending in the U.S. is anticipated to increase by 2025 with the country spending 20.1% of its GDP on healthcare. Healthcare expenditures in the U.S. are financed by both public payers and private insurance and individual payments. Schmid and Himmler (2015) suggest that the United States relies on employers to ensure health insurance coverage to its dependents due to lack of a universal system of health insurance. Health payments are covered by Centers for Medicare and Medicaid Services (CMS) and Private Commercial Insurers (PCIs). Despite the high spending on healthcare, the U.S. faces adverse health outcomes such as high infant mortality and low life expectancy. As stipulated by Chokshi et al. (2016) Lack of a coordinated healthcare system in the United States widens the inequality gap in access to healthcare wherein low-income families have reduced access to public health services and depend on subsidies and charity contribution to pay medical bills. Before the enactment of the ACA in 2010, which enhanced health insurance coverage, below-average income earners faced reduced access to care due to high costs. Inequalities in the U.S. healthcare system are primarily attributed to disparities in healthcare coverage among low-income and high-income Americans. Although recent changes in Medicare and Medicaid has changed eligibility requirements to include the aged and low-income families, disparity between the insured and uninsured still persists (CMS, 2014: Cohen et al., 2015). Dickman, Himmelstein and Woolhandler (2017) suggest that most uninsured persons in America earn annual incomes below the poverty line and are more likely than the insured to delay treatment and related medication due to high costs of care. Thus, the persistent inequality in the country hinder access to and provision of quality care among low-income earners, expanding the health gap further.

Inequalities in the U.S. healthcare system expose uninsured Americans to low-quality medical care such as wrong prescriptions and vaccinations. Institutional racism particularly renders ethnic minorities prone to persistent disparities in quality of care. For example, despite their proximity to high-quality hospitals, African-Americans are less likely to receive high-quality medical services such as surgeries than white patients (Dickman, Himmelstein, and Woolhandler, 2017). A study by Purkey and Mackenzie (2019) reveal that vulnerable communities such as the homeless have reduced access to the healthcare system, and in case they access these services, they receive low-quality care. The U.S. healthcare system is not accountable for minority populations seeking equity in healthcare. As a result, minority populations tend to avoid care, have unmet health needs, are stigmatized, and exposed to harm during care delivery. Inequality in healthcare financing cut a considerably higher share of the income earned by the less privileged than from the wealthy, increasing inequalities disposable income disparities (Dickman, Himmelstein, and Woolhandler, 2017). Funding of the U.S. healthcare system rely on private insurance and direct individual payments whereby the uninsured pay high health costs. The high costs of care subjects less privileged and minority communities to high medical bills and subsequent household debt.

 Recent changes in the U.S. healthcare include differences in Medicare and Medicaid to open eligibility for more people. Medicare has been reformed to expand coverage to people above 65 years of age and differently-abled persons (CMS, 2014). Medicaid, on the other hand, has been changed to extend coverage to eligible low- income persons and disabled persons. (Cohen et al., 2015). Private insurance health coverage has shifted towards health maintenance organization (HMO) system and the high deductible health plans (HGHPs), which have significantly improved quality, access to, and cost of care. Although ACA has dramatically improved health insurance coverage by insuring millions of Americans, recent American politics such as the Trump administration have attempted to replace ACA (Jacob and Skocpol, 2015). It is anticipated that attempts to replace ACA will continue in the future despite efforts by the American Health Care Act (AHCA) to replace the Obama reform. 

Research Question

1. How to address inequality in the provision of primary health care among marginalized communities?

Problem Statement

It is widely recognized that minority groups lag in access to primary health care services due to inequalities in the U.S. health care system. Primary Health Care (PHC) serves as a model for providing community health services aimed at reducing health inequalities and as an alternative to the dynamic nature of health care delivery. PHC services are founded on health standards defined by a society and can be accessed by all persons through active participation of the community. Public health is closely tied to PHC through health promotion, protection, and prevention of diseases. The primary care provided in clinical settings represents the immediate contact with the U.S. healthcare system that should be driven by continuity, coordination, and comprehensiveness. Although PHC is associated with positive health outcomes, efficiency, and equity, the extent to which health systems align with PHC best practices vary across states. The percentage of government spending allocated to PHC is estimated to range between 2% and 56% across low and middle-income countries Dickman, Himmelstein, and Woolhandler, 2017). The United States ranks low in primary care provision due to reduced availability and underutilization of primary care.

The widening economic inequality gap in the United States has increased disparities in the health system. Diagnosis and treatment of chronic illnesses follow a predictable pattern where a reduction in income increases the prevalence of chronic diseases. Such a trend in the U.S. has led to widening life expectancy gap between the rich and poor, particularly the gap between majority and minority communities (AHRQ, 2010). The health of minority communities is often overlooked, leading to unequal distribution of health care resources and care providers. Wealth inequality between majority and minority communities have fostered inequality in healthcare with majority communities recording higher access to health resources than the minorities. The service delivery and financing of health systems lead to unequal access to medical care and subsequent disparities in health status. Rising health costs for both insured and uninsured patients reduce disposable income, imposing substantial financial burdens on low-income families. Minority communities have been bankrupted by chronic illnesses and substantial medical bills while the affluent majorities adopt concierge practices defined by lengthy hospital visits and enhanced access to care providers. Although the health disparities among majority and minority communities are well documented, the shortage of care primary care providers and institutions serving marginalized communities reflect communities deprived health equity.  For example, a report by HHS (2016) shows that Native Americans are at higher risk of being overburdened by chronic diseases than Whites. Native Americans are 1.21 times likely to die from infectious diseases than Whites. The burden of these diseases results largely from reduced access to health services and uneven distribution of healthcare specialists.

Currently, there is a deficiency in the number of primary care providers needed to provide adequate care in America. Although the ACA is anticipated to expand health coverage to over 32 million uninsured Americans, there is the inadequacy of professionals to provide care to this group, especially in marginalized communities. PHC in the U.S. is delivered by family medicine, general internal medicine, and pediatrics comprising of about 222, 000 doctors. In addition to the shortage of care providers, primary care providers receive low wages which deprive them the incentives of serving marginalized communities. According to Association of American Medical Colleges (AAMC), medical students pursuing primary careers record $115 000 in debt, and most of them take time to recover from these debts or end up in bankruptcy. The dominant payment scheme used in primary care is a fee for service, which instead of enhancing continuity in care, it increases patient volume. 

Only 20% of new medical students pursue primary care, leading to a decline in the number of primary care professionals in the U.S (Knight, 2019). Additionally, primary care providers have reduced to no job satisfaction due to poor work conditions such as huge workloads and bureaucracy. A report by AAMC (2019) projects that there would be a shortage of up to 55, 200 primary care providers by 2032. This decline is associated with a high focus towards other specialties and overlooking primary care. Some medical schools in the U.S. do not enroll even a single student into primary care. Wage disparity between primary care professions and other specialties discourage medical students from applying for primary care professionals. 

Nevertheless, the Medicare program undervalues the services of primary care providers through cuts in annual payments to cover for increased healthcare costs. Underinvestment in primary care and inequality in financing makes it hard for primary care professionals to adopt models of care that could deliver high-quality care.

Shortage of primary care providers creates disparities in access to primary care between majority and minority communities. Research by Healthy people (2020) shows that the number of Americans with access to primary care providers has remained constant in almost two decades, with 76.4% in 2015 and 76.8% in 1996. Further, the research shows that a high proportion of Americans have been enrolled to HDHPs; 43% in 2017 and 15% in 2007, depicting the challenges in accessing primary care services. Unlike in traditional health insurance plans where access to primary care services was readily available for small co-payment, the HDHP requires patients to pay entirely for primary care until they spend their annual deductible. This deductible accumulated to $1500 for an individual and $2800 for a family in 2018. These figures indicate that even insured persons may not afford to pay for primary care services unless in extreme cases.  Shortage of primary services and care providers reduce access to primary care among minorities. 

Availability of primary care services correlates positively with the provision of high-quality care. Proximity to primary care institutions improves access to preventive and specialty services and subsequently improved health outcomes. Most primary care providers are concentrated in affluent suburbs, and people living in marginalized communities find it hard to access primary care services. Increase in racial and ethnic diversity in the U.S. has led to reduced and unequal diversification of primary care providers. Reduced diversity in various medical professions such as primary care, has led to unequal distribution of primary care providers, especially in marginalized regions. These regions have a higher proportion of family physicians than other physician specialists. Whites comprise the majority of physician specialties and low in the provision of internal medicine (Xierali and Nivet, 2018). Minorities such as Black and Asian physicians have higher proportions in internal medicine than in general specialties and family medicine.

Primary care physicians are unequally distributed across geographies with Black, Native American, and Hispanic groups in rural and marginalized regions. Racial and ethnic minorities are geographically concentrated and disproportionately attended to by a limited number of primary care providers. Most minorities receive low incomes and are underinsured, which affect their ability to access to primary care resources. Primary care providers with a high number of minority patients are located in low median income areas and lack health insurance coverage. Low-income patients in marginalized communities pose huge practice burdens for care providers due to poor health status, low socioeconomic conditions, and cultural barriers. A small number of primary care professionals disproportionate treat minority Medicare patients. Primary care providers in marginalized communities receive more than a third of their professional practice revenue from Medicaid. This revenue is inversely related to the number of minority patients in these areas. They also have low professional qualifications and reduced access to health care resources. Primary care providers in marginalized communities rely heavily on low-paying Medicaid reimbursements, earn low wages, and contribute heavily to uncompensated charity programs. This problem is compounded by health resource disparities, where marginalized communities have low Medicaid and private insurance reimbursements. 

 Inequality in the distribution of primary care subject racial and ethnic minorities to low-quality care. Despite improvements in hospitals serving minority communities, there still exist disparities in the provision of care due to institutional racism 

Research Hypotheses

1. Equality in the provision of primary care can be attained by reforming the mechanisms of paying for primary care services.

2. Improving the work conditions and compensations for primary care providers could increase the number of providers in marginalized communities. 

3. Reducing economic disparities could reduce income disparities between majority and minority communities, reducing health disparities and enhancing access to primary health care resources. 

References

“Access to Health Services.” Access to Health Services | Healthy People 2020, www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services.

Centers for Medicare & Medicaid Services (2014), Medicare Program – General Information [Online], Centers for Medicare & Medicaid Services. Available at: https://

www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html

Chokshi, D. A., Chang, J. E., & Wilson, R. M. (2016). Health reform and the changing safety net in the United States. The New England journal of medicine, 375(18), 1790.

Cohen, A. B., Colby, D. C., Wailoo, K. A. and Zelizer, J. E. (2015), ‘Introduction – Medicare, Medicaid, and the Moral Test of Government’, in Cohen, A. B., Colby, D. C., Wailoo, K. A. and Zelizer, J. E. (eds.) Medicare and Medicaid at 50, Oxford, Oxford University Press, pp. 11–20.

Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017). Inequality and the health-care system in the USA. The Lancet, 389(10077), 1431-1441.

Disparities in Health Care Quality among Racial and Ethnic Minority Groups: Selected Findings from the AHRQ 2010 NHQR and NHDR. Agency for Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/qual/nhqrdr10/nhqrdrminority1 0.htm

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HHS. Heart disease and African Americans. 2016b. [October 14, 2020]. 

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.

Jacobs, L., & Skocpol, T. (2015). Health care reform and American politics: What everyone needs to know, 3rd edition. 

Keehan, S. P., Poisal, J. A., Cuckler, G. A., Sisko, A. M., Smith, S. D., Madison, A. J., … & Lizonitz, J. M. (2016). National health expenditure projections, 2015–25: economy, prices, and aging expected to shape spending and enrollment. Health Affairs, 35(8), 1522-1531.

Knight, V. (2019). American Medical Students Less Likely To Choose To Become Primary Care Doctors. Retrieved 14 October 2020, from

https://www.physicianleaders.org/news/medical-students-primarycare-doctors

New Findings Confirm Predictions on Physician Shortage. (2019). Retrieved from

https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage

Purkey, E., & MacKenzie, M. (2019). Experience of healthcare among the homeless and vulnerably housed a qualitative study: Opportunities for equity-oriented health care. International Journal for Equity in Health, 18

Schmid, A., & Himmler, S. (2015). Netzwerkmedizin: Impulse für Deutschland aus den USA.

Starr, P. (2011). Remedy and reaction: The peculiar American struggle over health care reform. 

Xierali, I. M., & Nivet, M. A. (2018). The racial and ethnic composition and distribution of primary care physicians. Journal of health care for the poor and underserved, 29(1), 556.

Chapter 2

Literature Review

2.1 Overview

The debate about the efficiency of U.S. healthcare systems has infiltrated literature and

the public sphere. An efficient healthcare system ensures continuity, quality, affordability, access

to timely care, and uses of evidence-based practices to inform treatment decisions. High

healthcare costs and spending characterize healthcare in the U.S. The increased healthcare costs

and spending particularly drive the increased debate about the need to reform the Affordable

Care Act (ACA). Millions of Americans incur thousands of dollars in healthcare costs, paying

for healthcare premiums. A report by AHRQ highlights that the total health expenditures in the

U.S. summed up to approximately $3trillion in 2017. While this figure illuminates increased

utilization of health services, inequalities persist in the U.S. healthcare system, especially on

people of color and other marginalized communities. Institutional inequalities create gaps in

access to health services and resources, health insurance coverage, and poor health outcomes

among these marginalized groups. Although primary care is often used to reduce health

inequalities in healthcare systems, inequalities also exist in the provision of primary care services

in the U.S. health care system. This literature review explores various sources and theoretical

framework that explain inequalities in the U.S. healthcare system and the provision of primary

care services among

marginalized communities.

2.2 Inequalities in The U.S. Healthcare System

According to Braveman (2012), health inequalities refers to gaps in healthcare created by

differences in social class. Throughout history, health inequalities in the U.S have been defined

along with race and ethnicity. Widening health disparities in the U.S. are well documented with

Christina Scott
This section should not be here – omit. There is no introduction section in this chapter.

Christina Scott
Sub-headings should not be numbered. Also, there should not be an “overview” sub-heading.

marginalized groups, and low-income families are having the worst health outcomes. Despite

scant literature about the socioeconomic inequalities in health, recent data about inequalities in

the U.S. healthcare systems depict those disparities by economic class or ethnicity exist.

Dickman, Himmelstein, and Woolhandler (2017) attribute widening health disparities in America

to the increasing economic inequality in the U.S. Income disparity between the rich and low-

income families increase health disparities wherein the prevalence of diseases is inversely

proportional to income earned by low-income earners. Most wealth in the country is accumulated

by the rich, while the low-income earners and marginalized groups compete for limited

resources. Over 1.6 million families in America survive on incomes of below$2 per person every

day, extreme poverty.

Dickson, Himmelstein, and Woolhandler (2017) further explain that instead of reducing

the effects of economic inequality on health, the financing systems in the U.S healthcare system

perpetuate these effects through high health costs and spending. In affirmation, Blazheski and

Karp (2018) explain that inefficient regulation policies in the U.S. healthcare system increase

healthcare spending. The report highlights that 18% of the country’s GDP was spent on

healthcare, which accounted for $3.3 trillion in 2016. Despite high spending on healthcare, the

U.S has adverse health outcomes on metrics such as life expectancy and infant mortality rates. A

study by Van II (2018) agrees with these findings by depicting that most patients also spend

billions in paying for medical bills and health premiums.

Increased household spending on healthcare leads to income inequality and subsequent

disparities in utilization of health services. Even after the implementation of ACA, Americans

pay heavily for insurance premiums relative to the income differences between the rich and low-

income earners. Dickson, Himmelstein, and Woolhandler (2017) suggest that high health costs

Christina Scott
Good – this is a literature review!

Christina Scott
Nice!

render Americans to high medical bills, bankruptcy, and eventually push them to extreme

poverty. The high healthcare costs do not correspond with the increases in demand or quality of

care. While health insurance should aim at ensuring the provision of affordable care, a study by

Schmid and Himmler (2015) depicts that both the insured and uninsured persons incur high

medical costs, annulling the practicability of ACA.

On the contrary, Van II (2018) postulates that health insurance coverage has significantly

reduced medical bills. ACA particularly reduced the number of people affected by high medical

bills by 1.5 million people from 2010 to 2017. A report by the Centers for Disease Control

Prevention (CDCP) supports this idea by depicting a reduction in the percentage of American

overburdened by medical bills between 2011 and 2016 (Cohen and Zammitti, 2016). Health

disparities in the U.S result mainly from reduced health coverage and inadequate health

insurance among marginalized groups and low-income families. Minority groups in America

have problems accessing high-quality care than Whites due to their low median income.

Numerous studies show that despite expanded coverage by Medicare and Medicaid programs to

accommodate the elderly and low-income families, disparities in access to care still exist

(Dickman, Himmelstein, and Woolhandler (2017), Taylor (2019). Just like Dickman,

Himmelstein, and Woolhandler (2017), Taylor (2019) suggests that access to affordable

healthcare is a challenge to most marginalized groups.

Under coverage is the major issues hindering marginalized groups from accessing health

services like whites. For instance, 5.4 % of whites and 9.7% African-Americans were uninsured

in America in 2018 (Taylor, 2019). Most African Americans use private health insurance, while

others rely on Medicaid and other types of public health insurance. Taylor (2019) argues that

underinsurance among marginalized groups prompts them to spend $8,200 annually on health

Christina Scott
Great!

Christina Scott
Nice!

Christina Scott
Interesting.

care premiums and incur direct costs for services such as prescription drugs. This data is

congruent to findings by Dickman et al. (2017) that uninsured minority groups suffering from

diabetes spend $1446 direct costs for medical services annually and most of them do not have

access to primary care providers. Accordingly, low-income and uninsured Americans suffering

from chronic illnesses are less likely than the insured and high-income earners to go through

successful medical appointments.

While most of these authors attribute inequality in access to health services top widening

health disparities in the U.S, a report by Blair et al. (2011) shows that minorities still receive

low-quality care due to implied bias from care providers. Although the extent of this bias varies,

the presence of implicit bias in the U.S healthcare system is consistent throughout the study,

suggesting that care providers have an inherent prejudice towards minorities in society.

However, the authors did not point out the impact of care providers’ implicit bias on minorities’

health care outcomes. Instead, the authors noted that other studies have shown a positive

correlation between care providers bias and perceived health outcomes whereby racial ideology

is used to inform treatment plans.

Similarly, statistics by the American College of Physicians (2010) showed that minorities

have less access to healthcare services and receive poorer quality of care than whites. Based on

the literature presented, it is apparent that inequalities in the U.S. healthcare system are largely

due to inequality in access to healthcare services and provision of low-quality among minority

groups. The disparities in healthcare discussed in this section are by no means comprehensive

since other factors could be considered, such as language and religious barriers. Nevertheless,

there is a need to recognize the problems faced by minorities in accessing healthcare and

receiving low-quality care.

Christina Scott
Ah-ha! Is this a gap in the research? I’m thinking your RQ should specifically be focused on PHC and minority access somehow.

Christina Scott
How does this knowledge impact your RQ?

Christina Scott
Nice!

2.3 Primary Care and The U.S. Health System

Despite high health costs and spending in the U.S. healthcare system, the country still has

adverse health outcomes. One of the major factors contributing to these outcomes is reduced

emphasis on primary care within the health system (Weidner and Davis, 2018). Currently, there

is a gap in the utilization of primary care services and the supply of the number of care providers

needed to deliver primary care to the entire American population. This gap makes it imperative

to understand various issues such as the extent to which medical students enroll to study primary

care, the supply of care providers among marginalized communities and inequalities in the

delivery of primary care services.

Medical students’ choice of specialty is well documented. Weidner and Davis (2018)

argued that the process of medical education hinder medical students from choosing primary

care. Peterson et al. (2018) support this argument by noting that American medical education

underlies on a hidden curriculum that favor specialist over generalist, which discourage students

from pursuing primary care. Most students in the study associated primary care with low-prestige

as cited by Lahad at et al. (2018). Even these students showed interest in primary care,

Weissman et al. (2018) discovered that they were inclined to pursue a primary care specialty in

urban areas and disinterested in marginalized regions. The cornerstone of primary is based partly

on reducing health inequalities and social factors that hindered people from accessing care. The

gap in reimbursement for primary care providers and high students’ debt discourage students

from pursuing primary care specialty (Kruse, 2013). Primary care is the lowest paid medical

professionals in the United States. Primary care providers include family and general

practitioners, internists, and pediatricians. States in the United States that have a high number of

primary healthcare providers recorded positive health outcomes such as reduced mortality rates.

On the contrary, a study by van Dorn, Cooney, and Sabin (2020) reported that both primary care

and income inequality influence health outcomes. These findings suggest that the reduced supply

of primary care providers in the U.S produce adverse health outcomes among the affected

populations. Availability of primary care providers determined the number of persons that

accessed primary care services.

A report by Shi et al. (2017) indicated that the percentage of the American population

with access to primary care provider stagnated between 1996 and 2015 from 76.8% to 76.4%

respectively. This problem is compounded by the fact that a high proportion of American

population has been enrolled into high-deductible health plans (HDHPS) from 15% in 2007 to

43% in 2017 (Shi et al., 2017). This shift has made it hard for minorities and low-income

families to access primary care services. In 2018, the average HDHP deductible for one person

ranged at $1500 and $2800 for a household. The research concluded that most Americans,

especially low-income families, could not afford primary care even those with health insurance.

This literature review highlights the need for increased emphasis on primary healthcare to reform

the education system for medical students, improve the supply of primary care providers, and

enhance access to primary care, especially by marginalized groups.

2.4 Inequality in the U.S Primary Care.

Primary health care focuses on providing care to individuals by taking care services and

medical interventions near to that population. An evaluation study for value-based care by Ma et

al. (2019) described that provision of primary care is determined by practices that incorporate

individuals social, environmental, political, cultural, and epidemiological aspects of a

community. The author emphasized that access is integral to the supply and distribution of

healthcare services and play a vital role in ensuring equality in health systems.

Christina Scott
Is this informatin in the PS?

Minority groups remain vulnerable and deficient in terms of accessing and being included

in primary healthcare programs. As such, Ma et al. (2019) concluded that access to primary

healthcare by minorities is constrained by various factors such as lack of health insurance,

documentation and length of stay in America. This conclusion aligns with findings by Heath

(2019), which showed that health inequalities existed along racial lines whereby adult patients

from minority groups were less likely to consult a primary care provider than their white peers.

Particularly, patients residing in the South were less likely to have primary care providers than

patients in other parts of the United States. The U.S. Census Bureau Annual Estimates (2019)

deduced that the shortage of care providers in marginalized regions produce racial and disparities

in access to primary care.

Minority populations affected by these inequalities between 2013 to 2015 were Hispanic

and black adults and non-white adults. These disparities are explained by lack of access to

primary care services. Primary care institutions and physicians are concentrated in urban areas

(Douthit et al., 2015). However, this abundance in urban areas does not increase the supply of

primary care providers in rural areas inhabited by low-income families and minority populations.

As a result, both the urban poor and marginalized groups report difficulties in obtaining primary

care services. Inadequate primary care services among these people are attributed to various

disincentives for primary care providers such as increased reliance on Medicaid, poverty, few

people with disposable income, and high rates of noncompliance in treatment interventions.

Medicaid also undervalues physicians by paying them low incomes and charging them

high administrative costs, which discourage them from serving in marginalized communities.

Nevertheless, de Andrade et al. (2015) agrees that reduced access to primary care services for

marginalized communities implies that minorities living in extreme poverty are less likely to

Christina Scott
Good

receive care frequently than Whites and tend to rely heavily on hospital-based care. This

preference for hospital-based care is perpetuated by residential segregation and location of

hospitals, and financial barriers such as payment for insurance premiums. This problem is

recognized by Buerhaus (2018), who highlighted the need for affordable primary services in

marginalized communities.

2.5 Theoretical Frameworks

Various theoretical frameworks have been adopted to explain inequalities in healthcare

systems. Current theories focus on the social determinants of health to explain health disparities.

The social production of the political economy of health framework suggests that the relationship

between economic inequality and health must address the structural cause of inequalities

(Arcaya, Arcaya, and Subramanian, 2015). This implies that the effect of economic inequality on

health mirrors the lack of resources and wealth accumulated across a plethora of community

infrastructure. Economic and political powers influence the amount of wealth accumulated by

individuals and shape the nature of public health (Watt and Sheiham, 2012). In this regard,

economic inequality reflects the material conditions that affect population health. Various

researchers support this aspect and emphasize that health inequalities result from differences in

the accumulation of material resources. Accordingly, people with resources such as health

knowledge, social connections, wealth, and power can avoid health risks by seeking medical

services and adopt prevention measures available at a given time and place.

Another most used theoretical framework is a life course perspective. Researchers have

used this model to explain how various social determinants of health operate at every level of

human development to influence health (Corna, 2013; Arcaya, Arcaya, and Subramanian, 2015).

Christina Scott
Strong theoretical selections and discussion!

Christina Scott
I wonder if there is becoming such a thing as “health capital”, like “cultural capital”?

Particularly, research focus on the accumulation of risk perspective by suggesting that factors

that promote good health are accumulated gradually throughout a person’s life course. In this

regard, a person’s childhood social class experiences can be accumulated and influence later

health life. For instance, exposure to educational activities during childhood and early adulthood,

influence a person’s income level during adulthood, and health in adulthood. Jones et al. (2019)

criticize this theory and suggest that the theory should integrate both biological and social

transmission of health and risks across generations.

On the contrary, Brotman, Ferrer, and Koehn (2020) used this theory to develop an

understanding of health disparities across countries and populations. The author suggests that

health inequalities lie in socially-structured exposures at different stages of a person’s life. Low-

income in adult life has huge health impacts on a person who grew up in a low-income family by

amplifying the health effects of extreme poverty. Brown (2018) argued along this line and notes

that early life conditions among marginalized groups are vital in explaining current health

inequalities. Disparities in access to health services at early life generate stress and health

behaviors which influence the health status of marginalized groups in future.

References

American College of Physicians. Racial and Ethnic Disparities in Health Care, Updated 2010.

Philadelphia: American College of Physicians; 2010: Policy Paper. (Available from

American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA

19106.)

Christina Scott
This is not a scholarly journal article, but I will accept it due to its relation to scholarly research.

America’s Health Rankings analysis of Special data request for information on active state

licensed physicians provided by Redi-Data, Inc., Sept. 23, 2019; U.S. Census Bureau

Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2018, United

Health Foundation, AmericasHealthRankings.org, Accessed 2020.

Arcaya, M. C., Arcaya, A. L., & Subramanian, S. V. (2015). Inequalities in health: definitions,

concepts, and theories. Global health action, 8(1), 27106.

Bates, D. W. (2010). Primary care and the US health care system: what needs to change? Journal

of general internal medicine, 25(10), 998-999.

Blair, I. V., Steiner, J. F., & Havranek, E. P. (2011). Unconscious (implicit) bias and health

disparities: where do we go from here? The Permanente Journal, 15(2), 71.

Blazheski, F., & Karp, N. (2018). Got symptoms? High US healthcare spending and its long-

term impact on economic growth. US Economic Watch, 10-20.

Braveman, P. (2012). Health inequalities by class and race in the US: What can we learn from

the patterns? Social science & medicine, 74(5), 665-667.

Brown, T. H. (2018). Racial stratification, immigration, and health inequality: A life course-

intersectional approach. Social Forces, 96(4), 1507-1540.

Brotman, S., Ferrer, I., & Koehn, S. (2020). Situating the life story narratives of aging

immigrants within a structural context: the intersectional life course perspective as

research praxis. Qualitative Research, 20(4), 465-484.

Buerhaus, P. (2018). Nurse practitioners: A solution to America’s primary care crisis. American

Enterprise Institute, 1-30.

Cohen, R. A., & Zammitti, E. P. (2016). Problems paying medical bills among persons under age

65: early release of estimates from the National Health Interview Survey 2011-June 2016.

In Statistics NCfH.

Corna, L. M. (2013). A life course perspective on socioeconomic inequalities in health: a critical

review of conceptual frameworks. Advances in life course research, 18(2), 150-159.

de Andrade, L. O. M., Pellegrini Filho, A., Solar, O., Rígoli, F., de Salazar, L. M., Serrate, P. C.

F., … & Atun, R. (2015). Social determinants of health, universal health coverage, and

sustainable development: case studies from Latin American countries. The

Lancet, 385(9975), 1343-1351.

Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to

health care access in the rural USA. Public health, 129(6), 611-620.

Heath, S. (2019). Primary Care Access Drops 2%, Prompting Calls for Policy Change.

https://patientengagementhit.com/news/primary-care-access-drops-2-prompting-calls-for-

policy-change

Jones, N. L., Gilman, S. E., Cheng, T. L., Drury, S. S., Hill, C. V., & Geronimus, A. T. (2019).

Life course approaches to the causes of health disparities. American journal of public

health, 109(S1), S48-S55.

Kruse, J. (2013). Income ratio and medical student specialty choice: the primary importance of

the ratio of mean primary care physician income to mean consulting specialist

income. Family medicine, 45(4), 281.

https://patientengagementhit.com/news/primary-care-access-drops-2-prompting-calls-for-policy-change

https://patientengagementhit.com/news/primary-care-access-drops-2-prompting-calls-for-policy-change

Lahad, A., Bazemore, A., Petek, D., Phillips, W. R., & Merenstein, D. (2018). How can we

change medical students’ perceptions of a career in family medicine? Marketing or

substance? Israel journal of health policy research, 7(1), 52.

Ma, Q., Sylwestrzak, G., Oza, M., Garneau, L., & DeVries, A. R. (2019). Evaluation of value-

based insurance design for primary care. Am J Manag Care, 25(5), 221-227.

Peterson, L. E., Fang, B., Puffer, J. C., & Bazemore, A. W. (2018). Wide gap between

preparation and scope of practice of early career family physicians. The Journal of the

American Board of Family Medicine, 31(2), 181-182.

Shi, Y., Yi, H., Zhou, H., Zhou, C., Xue, H., Rozelle, S., … & Sylvia, S. (2017). The quality of

primary care and correlates among grassroots providers in rural China: a cross-sectional

standardised patient study. The Lancet, 390, S16.

Schmid, A. and Himmler, S. (2015), Netzwerkmedizin: Impulse für Deutschland aus den USA,

Stiftung Münch.

Taylor, J. (2019). Racism, Inequality, and Health Care for African Americans.

https://tcf.org/content/report/racism-inequality-health-care-african-americans/?

session=1&session=1&session=1

van Dorn, A., Cooney, R. E., & Sabin, M. L. (2020). COVID-19 exacerbating inequalities in the

US. Lancet (London, England), 395(10232), 1243.

Watt, R. G., & Sheiham, A. (2012). Integrating the common risk factor approach into a social

determinants framework. Community dentistry and oral epidemiology, 40(4), 289-296.

Christina Scott
Did you read this in German?!

https://tcf.org/content/report/racism-inequality-health-care-african-americans/?session=1&session=1&session=1

https://tcf.org/content/report/racism-inequality-health-care-african-americans/?session=1&session=1&session=1

Weidner, A., & Davis, A. (2018). Influencing medical student choice of primary care worldwide:

international application of the four pillars for primary care physician workforce. Israel

journal of health policy research, 7(1), 1-4.

Weissman, C., Zisk-Rony, R. Y., Avidan, A., Elchalal, U., & Tandeter, H. (2018). Challenges to

the Israeli healthcare system: attracting medical students to primary care and to the

periphery. Israel journal of health policy research, 7(1), 28.

II, V. (2018). The American Health-Care System Increases Income Inequality.

https://www.theatlantic.com/politics/archive/2018/01/health-care-income-inequality-

premiums-deductibles-costs/550997/

https://www.theatlantic.com/politics/archive/2018/01/health-care-income-inequality-premiums-deductibles-costs/550997/

https://www.theatlantic.com/politics/archive/2018/01/health-care-income-inequality-premiums-deductibles-costs/550997/

Chapter 1

Introduction

Introduction

The U.S. healthcare system comprises of a complex organization focused on providing

coordinated, affordable, efficient and high-quality care. Despite the implementation of health

policies such as the Affordable Care Act (ACA) to provide cost-effective care, reduce the

uninsured rate and enhance access to care, the healthcare cost and spending in the United States

are still high. A high percentage of the country’s Gross Domestic Product (GDP) is spent on

healthcare, higher than the amount spent by other countries in the Organization for Economic

Cooperation and Development (OECD). According to Keehan et al. (2016), healthcare spending

in the U.S. is anticipated to increase by 2025 with the country spending 20.1% of its GDP on

healthcare. Healthcare expenditures in the U.S. are financed by both public payers and private

insurance and individual payments. Schmid and Himmler (2015) suggest that the United States

relies on employers to ensure health insurance coverage to its dependents due to lack of a

universal system of health insurance. Health payments are covered by Centers for Medicare and

Medicaid Services (CMS) and Private Commercial Insurers (PCIs). Despite the high spending on

healthcare, the U.S. faces adverse health outcomes such as high infant mortality and low life

expectancy. As stipulated by Chokshi et al. (2016) Lack of a coordinated healthcare system in

the United States widens the inequality gap in access to healthcare wherein low-income families

have reduced access to public health services and depend on subsidies and charity contribution to

pay medical bills. Before the enactment of the ACA in 2010, which enhanced health insurance

coverage, below-average income earners faced reduced access to care due to high costs.

Inequalities in the U.S. healthcare system are primarily attributed to disparities in healthcare

coverage among low-income and high-income Americans. Although recent changes in Medicare

and Medicaid has changed eligibility requirements to include the aged and low-income families,

disparity between the insured and uninsured still persists (CMS, 2014: Cohen et al., 2015).

Dickman, Himmelstein and Woolhandler (2017) suggest that most uninsured persons in America

earn annual incomes below the poverty line and are more likely than the insured to delay

treatment and related medication due to high costs of care. Thus, the persistent inequality in the

country hinder access to and provision of quality care among low-income earners, expanding the

health gap further.

Inequalities in the U.S. healthcare system expose uninsured Americans to low-quality

medical care such as wrong prescriptions and vaccinations. Institutional racism particularly

renders ethnic minorities prone to persistent disparities in quality of care. For example, despite

their proximity to high-quality hospitals, African-Americans are less likely to receive high-

quality medical services such as surgeries than white patients (Dickman, Himmelstein, and

Woolhandler, 2017). A study by Purkey and Mackenzie (2019) reveal that vulnerable

communities such as the homeless have reduced access to the healthcare system, and in case they

access these services, they receive low-quality care. The U.S. healthcare system is not

accountable for minority populations seeking equity in healthcare. As a result, minority

populations tend to avoid care, have unmet health needs, are stigmatized, and exposed to harm

during care delivery. Inequality in healthcare financing cut a considerably higher share of the

income earned by the less privileged than from the wealthy, increasing inequalities disposable

income disparities (Dickman, Himmelstein, and Woolhandler, 2017). Funding of the U.S.

healthcare system rely on private insurance and direct individual payments whereby the

uninsured pay high health costs. The high costs of care subjects less privileged and minority

communities to high medical bills and subsequent household debt.

Recent changes in the U.S. healthcare include differences in Medicare and Medicaid to

open eligibility for more people. Medicare has been reformed to expand coverage to people

above 65 years of age and differently-abled persons (CMS, 2014). Medicaid, on the other hand,

has been changed to extend coverage to eligible low- income persons and disabled persons.

(Cohen et al., 2015). Private insurance health coverage has shifted towards health maintenance

organization (HMO) system and the high deductible health plans (HGHPs), which have

significantly improved quality, access to, and cost of care. Although ACA has dramatically

improved health insurance coverage by insuring millions of Americans, recent American politics

such as the Trump administration have attempted to replace ACA (Jacob and Skocpol, 2015). It

is anticipated that attempts to replace ACA will continue in the future despite efforts by the

American Health Care Act (AHCA) to replace the Obama reform.

Research Question

1. How to address inequality in the provision of primary health care among marginalized

communities?

Problem Statement

It is widely recognized that minority groups lag in access to primary health care services

due to inequalities in the U.S. health care system. Primary Health Care (PHC) serves as a model

for providing community health services aimed at reducing health inequalities and as an

alternative to the dynamic nature of health care delivery. PHC services are founded on health

standards defined by a society and can be accessed by all persons through active participation of

the community. Public health is closely tied to PHC through health promotion, protection, and

Christina Scott
This is getting there. I think you already know a lot of the issues (as noted in PS and hypotheses), so I’d like to see perhaps a more specific RQ on one independent variables that could help reduce inequality in PHC among marginalized communities.

Christina Scott
This should not be numbered.

prevention of diseases. The primary care provided in clinical settings represents the immediate

contact with the U.S. healthcare system that should be driven by continuity, coordination, and

comprehensiveness. Although PHC is associated with positive health outcomes, efficiency, and

equity, the extent to which health systems align with PHC best practices vary across states. The

percentage of government spending allocated to PHC is estimated to range between 2% and 56%

across low and middle-income countries Dickman, Himmelstein, and Woolhandler, 2017). The

United States ranks low in primary care provision due to reduced availability and

underutilization of primary care.

The widening economic inequality gap in the United States has increased disparities in

the health system. Diagnosis and treatment of chronic illnesses follow a predictable pattern

where a reduction in income increases the prevalence of chronic diseases. Such a trend in the

U.S. has led to widening life expectancy gap between the rich and poor, particularly the gap

between majority and minority communities (AHRQ, 2010). The health of minority communities

is often overlooked, leading to unequal distribution of health care resources and care providers.

Wealth inequality between majority and minority communities have fostered inequality in

healthcare with majority communities recording higher access to health resources than the

minorities. The service delivery and financing of health systems lead to unequal access to

medical care and subsequent disparities in health status. Rising health costs for both insured and

uninsured patients reduce disposable income, imposing substantial financial burdens on low-

income families. Minority communities have been bankrupted by chronic illnesses and

substantial medical bills while the affluent majorities adopt concierge practices defined by

lengthy hospital visits and enhanced access to care providers. Although the health disparities

among majority and minority communities are well documented, the shortage of care primary

care providers and institutions serving marginalized communities reflect communities deprived

health equity. For example, a report by HHS (2016) shows that Native Americans are at higher

risk of being overburdened by chronic diseases than Whites. Native Americans are 1.21 times

likely to die from infectious diseases than Whites. The burden of these diseases results largely

from reduced access to health services and uneven distribution of healthcare specialists.

Currently, there is a deficiency in the number of primary care providers needed to

provide adequate care in America. Although the ACA is anticipated to expand health coverage to

over 32 million uninsured Americans, there is the inadequacy of professionals to provide care to

this group, especially in marginalized communities. PHC in the U.S. is delivered by family

medicine, general internal medicine, and pediatrics comprising of about 222, 000 doctors. In

addition to the shortage of care providers, primary care providers receive low wages which

deprive them the incentives of serving marginalized communities. According to Association of

American Medical Colleges (AAMC), medical students pursuing primary careers record $115

000 in debt, and most of them take time to recover from these debts or end up in bankruptcy. The

dominant payment scheme used in primary care is a fee for service, which instead of enhancing

continuity in care, it increases patient volume.

Only 20% of new medical students pursue primary care, leading to a decline in the

number of primary care professionals in the U.S (Knight, 2019). Additionally, primary care

providers have reduced to no job satisfaction due to poor work conditions such as huge

workloads and bureaucracy. A report by AAMC (2019) projects that there would be a shortage

of up to 55, 200 primary care providers by 2032. This decline is associated with a high focus

towards other specialties and overlooking primary care. Some medical schools in the U.S. do not

enroll even a single student into primary care. Wage disparity between primary care professions

and other specialties discourage medical students from applying for primary care professionals.

Nevertheless, the Medicare program undervalues the services of primary care providers through

cuts in annual payments to cover for increased healthcare costs. Underinvestment in primary care

and inequality in financing makes it hard for primary care professionals to adopt models of care

that could deliver high-quality care.

Shortage of primary care providers creates disparities in access to primary care between

majority and minority communities. Research by Healthy people (2020) shows that the number

of Americans with access to primary care providers has remained constant in almost two

decades, with 76.4% in 2015 and 76.8% in 1996. Further, the research shows that a high

proportion of Americans have been enrolled to HDHPs; 43% in 2017 and 15% in 2007, depicting

the challenges in accessing primary care services. Unlike in traditional health insurance plans

where access to primary care services was readily available for small co-payment, the HDHP

requires patients to pay entirely for primary care until they spend their annual deductible. This

deductible accumulated to $1500 for an individual and $2800 for a family in 2018. These figures

indicate that even insured persons may not afford to pay for primary care services unless in

extreme cases. Shortage of primary services and care providers reduce access to primary care

among minorities.

Availability of primary care services correlates positively with the provision of high-

quality care. Proximity to primary care institutions improves access to preventive and specialty

services and subsequently improved health outcomes. Most primary care providers are

concentrated in affluent suburbs, and people living in marginalized communities find it hard to

access primary care services. Increase in racial and ethnic diversity in the U.S. has led to reduced

and unequal diversification of primary care providers. Reduced diversity in various medical

professions such as primary care, has led to unequal distribution of primary care providers,

especially in marginalized regions. These regions have a higher proportion of family physicians

than other physician specialists. Whites comprise the majority of physician specialties and low in

the provision of internal medicine (Xierali and Nivet, 2018). Minorities such as Black and Asian

physicians have higher proportions in internal medicine than in general specialties and family

medicine.

Primary care physicians are unequally distributed across geographies with Black, Native

American, and Hispanic groups in rural and marginalized regions. Racial and ethnic minorities

are geographically concentrated and disproportionately attended to by a limited number of

primary care providers. Most minorities receive low incomes and are underinsured, which affect

their ability to access to primary

care resources.

Primary care providers with a high number of

minority patients are located in low median income areas and lack health insurance coverage.

Low-income patients in marginalized communities pose huge practice burdens for care providers

due to poor health status, low socioeconomic conditions, and cultural barriers. A small number

of primary care professionals disproportionate treat minority Medicare patients. Primary care

providers in marginalized communities receive more than a third of their professional practice

revenue from Medicaid. This revenue is inversely related to the number of minority patients in

these areas. They also have low professional qualifications and reduced access to health care

resources. Primary care providers in marginalized communities rely heavily on low-paying

Medicaid reimbursements, earn low wages, and contribute heavily to uncompensated charity

programs. This problem is compounded by health resource disparities, where marginalized

communities have low Medicaid and private insurance reimbursements.

Inequality in the distribution of primary care subject racial and ethnic minorities to low-quality

care. Despite improvements in hospitals serving minority communities, there still exist

disparities in the provision of care due to institutional racism

Research Hypotheses

1. Equality in the provision of primary care can be attained by reforming the mechanisms of

paying for primary care services.

2. Improving the work conditions and compensations for primary care providers could

increase the number of providers in marginalized communities.

3. Reducing economic disparities could reduce income disparities between majority and

minority communities, reducing health disparities and enhancing access to primary health

care resources.

Christina Scott
I think there are too many variables presented in these hypotheses. Each almost reads more like an RQ than an RH as well. My concern is your ability to test these specific independent variables (i.e. reforming the mechanisisms of paying…, improving the work conditions, and reducing economic disparities). It will be hard to find data sets that examine all of these issues as well. Have you found a data set that examines one of these variables in one of hypotheses?

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