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Economic Disparities Drive Widening Rift in Health Care Access and Quality

Health Affairs Article: Americans Willing to Pursue Health Care Excellence for Some, While Tolerating the Deterioration of Care for Others

News Release
Dec. 6, 2005

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—As health care gobbles up an ever-larger share of the U.S. economy, the inability or unwillingness to ensure equal access to high-quality health care is fueling a widening rift between rich and poor Americans, according to a study by the Center for Studying Health System Change (HSC) published today as a Web-exclusive article in the journal Health Affairs.

"Increasingly, America is turning into a country of health care haves and have nots, driven primarily by the type of—or lack of—health coverage people have," said lead author Robert E. Hurley, Ph.D., an HSC senior consulting researcher and associate professor at Virginia Commonwealth University. HSC is a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation.

Many recent health care investments and initiatives are focused on affluent communities and are accessible mainly to people with employer-based or Medicare coverage, while access to basic care for people with Medicaid or no coverage at all is worsening in the wake of stalled coverage expansions and service cuts, according to the article.

The Health Affairs article, titled "A Widening Rift in Access and Quality: Growing Evidence of Economic Disparities," is based on HSC’s 2005 site visits to 12 nationally representative communities—Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. HSC has been tracking change in these markets for the past 10 years.

"A clear hierarchy of access to care is emerging in many communities—there is growing evidence that U.S. society is willing to tolerate almost limitless access to care for some and deteriorating access to basic care for others," said Hoangmai H. Pham, M.D., M.P.H., an HSC senior researcher and study coauthor, along with HSC Consulting Researcher Gary Claxton of the Kaiser Family Foundation.

Two perspectives written by Eric Book, chief medical officer of Blue Shield of California, and Timothy Ferris and David Blumenthal of Harvard Medical School, accompany the article. Book advocates universal coverage to address coverage gaps, while Ferris and Blumenthal support strengthening safety net providers.

Other key findings of the HSC study include:

  • While the distribution of lower-income patients has long been skewed toward certain providers, evidence suggests these lines of segregation are hardening, driven largely by the dictates of geography and channeled in part through growing disparities in access to physician care. Underlying this phenomenon is the interaction of two major trends: 1) growth of investments by both hospital systems and physicians in specialty services and relocated services, such as diagnostic testing from inpatient to outpatient settings; 2) and the recent burst of hospital facility expansions.
  • Hospital expansions in affluent areas have the potential to worsen disparities when they reflect a differential investment of resources between poorer and wealthier communities. Institutions serving poorer populations begin with significant disadvantages, as they are less likely to have sufficient capital or the financial health to obtain debt financing to invest in new building.
  • Hospitals and physicians are increasing specialization of medical care, including acquiring and applying new diagnostic and treatment techniques and technologies, in both full-service and freestanding facilities. Hospitals are engaged in major construction initiatives after a decade-long lull in capital expenditures. Some projects have been undertaken to upgrade facilities to make them more suitable for providing state-of-the art-care at the level of contemporary customer—patient and physician—expectations. Other projects involve extending services to new locations closer to more affluent and well-insured customers.
  • State and local budget shortfalls and resulting Medicaid payment freezes and reductions have worsened access problems to key services like mental and dental care, as well as many types of specialty care. Applying copayments, eliminating benefits, and setting arbitrary limits on services is seen by some observers as "cost-shirking" that leaves providers caring for these patients in the position of either dropping them or absorbing the cost of their uncompensated care.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.

Health Affairs, published by Project HOPE, is the leading journal of health policy.


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The Center for Studying Health System Change Ceased operation on Dec. 31, 2013.