Racial and Ethnic Disparities in Access to Health Care Among Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018

Abstract

Importance: Racial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed.

Objectives: To determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades.

Design: Cross-sectional.

Setting: Data from the National Health Interview Survey, 1999-2018.

Participants: Individuals >18 years old.

Exposure: Race and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic.

Main outcome and measures: Rates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes.

Results: We included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (-2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (-1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016-2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (-4.9%) and Asians (-6.4%).

Conclusions and relevance: Insurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals.

Key points: Question: In the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities?Findings: Using National Health Interview Survey data from 1999-2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care.Meaning: Despite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.

Figure 1.

Annual age- and region-adjusted percentage of uninsured adults in the US by race/ethnicity, 1999 to 2018.

Figure 2.

Annual age- and region-adjusted percentage of adults in the US who reported foregoing or delaying medical care due to cost in the past 12 months by race/ethnicity, 1999 to 2018.

Figure 3.

Age- and region-adjusted annual percentage of adults in the US without a usual source of care by race/ethnicity, 1999 to 2018.