Access to health care services is a concern in communities across the United States. Some of the potential barriers to access include a lack of health insurance, under-insurance, and a lack providers accepting all forms of health care coverage. Other issues such as language or cultural barriers, transportation, inadequate child care options, or restrictive hours of service, further complicate the situation.

Furthermore, access restrictions are disparately felt among community members, disproportionately affecting those in lower socio-economic strata, those without insurance, and communities of color. Difficulties in addressing access issues for recent immigrants and undocumented residents are compounded by a lack of data about these population groups.

ease of access to local health care services

From 1998 survey findings:

• Overall, 60.1% of San Mateo County survey respondents rate the ease of accessing local health care as "excellent" or "very good." Another 25.9% rate it as "good." ⁴⁴⁴

• In contrast, 14% of respondents believe that access to local health care is "fair" or "poor." Higher "fair/poor" evaluations are noted among:

  *  Community residents with no health care insurance coverage (42.3%);
  *  Those living below the 185% poverty threshold (26%);
  *  Coastside residents (22.5%);
  *  Hispanics (19%); and
  *  Those with a high school education or less (17.7%).⁴⁴⁵

   

accessibility of specialized care

1998 survey respondents were asked to evaluate the ease of access to each of five specific types of health care services.

• Of the tested services, San Mateo County respondents were most critical of access to mental health services (28.1% rate this as "fair/poor). While evaluations are close when looking at income levels, note that 38.2% of uninsured respondents give "fair" or "poor" evaluations. ⁴⁴⁶

• Access to substance abuse services received the second-highest "fair/poor" response among San Mateo County respondents overall (23.2%). Among the uninsured, this response increases to 36.6%. ⁴⁴⁷

• Access to child health services received the third-highest "fair/poor" response among San Mateo County respondents (17.3%). Note the wider discrepancy by income level in the evaluations for child health, as well as vision and dental

health insurance coverage

1998 survey findings reveal the following items relating to health care insurance coverage in San Mateo County:

• Three out of four San Mateo County respondents aged 18 to 64 report that they have coverage through an employer, either their own (56.4%) or someone else’s (17.9%). A total of 10.6% say they have a health insurance plan they purchase on their own. Another 3.8% have a government-sponsored plan (e.g., Medi-Cal, Medicare, military health benefits). ⁴⁴⁹

  *  Among employed residents aged 18 to 64, 79.6% have coverage provided through an employer, and 9.6% use a plan they purchase on their own. ⁴⁵⁰

• However, 11.3% of adults aged 18 to 64 do not have job-based, privately purchased, or government-sponsored health insurance (representing approximately 50,127 adults aged 18 to 64). Of these respondents, 75% say they have no coverage at all (approximately 37,595 adults 18 to 64), while 17.4% cite some "other" source, and 7.6% don’t know. [Note that these figures exclude children, of whom a greater share may be uninsured.] Statewide, it is estimated that 22.7% of adults 18-64 do not have health insurance coverage.⁴⁵¹
• African-American respondents had the highest prevalence of being uninsured (34%), followed by Hispanics (18.1%), Asians/Pacific Islanders (3.6%) and Whites (3.1%). [Note, however, that the percentage for African-Americans carries a relatively high error rate because the sample size was small.] ⁴⁵²

• Among uninsured respondents, 23.1% report that they have never had health insurance; 15.8% say they have had health insurance, but it had been more than five years since they were covered. A total of 29.9% say they have been uninsured for less than a year. ⁴⁵³

• Since the implementation of welfare reform in August 1996, the number of individuals eligible for Medi-Cal through the TANF program has declined, the number of individuals eligible for Medi-Cal only has remained about the same, and the number of elderly and disabled individuals eligible for Medi-Cal has remained about the same. ⁴⁵⁴

• About 30% of the members in San Mateo County’s Medi-Cal managed care plan, the Health Plan of San Mateo, are dually eligible for Medicare and Medi-Cal. These members are eligible for Medicare due to age and/or disability, and for Medi-Cal due to income. ⁴⁵⁵

• Among insured respondents, 7.8% describe a time in the preceding year in which they did not have health insurance coverage. ⁴⁵⁶

• In the 1998 survey, 77.6% of employed San Mateo County adults report that their employer offers health care benefits; those without benefits are more often part-time workers or employed in service or labor-intensive occupations. Furthermore, among those whose employers offer benefits, 94.9% report that benefits are also available for dependents.⁴⁵⁷

dental insurance

• 26.6% of survey participants aged 18 to 64 currently do not have any type of insurance coverage for routine dental care (either full or partial coverage). Lack of dental insurance is highest among those living below the 185% poverty threshold (53.8%). ⁴⁵⁸

Other Potential Barriers to Access

Other than lack of insurance coverage, a variety of other factors have the potential for restricting access to health care services for many community residents. In the 1998 San Mateo County Quality of Life Survey, five additional potential barriers to access were addressed:

difficulty getting in to see a doctor

• A total of 15.4% of survey respondents report that they have had difficulty getting in to see a doctor in the past year. This includes:

*  22.8% of Hispanics
*  15.7% of Whites
*  8.9% of Asians/Pacific Islanders
*  8.7% of African-Americans ⁴⁵⁹

inconvenient office hours

• A total of 15.2% of respondents report that there has been a time in the past year when they needed to see a doctor, but could not because the office hours were not convenient. This percentage increases among various demographic breakouts:

*  21.2% among African-Americans and 22.5% among Hispanic community members (vs. 12.3% among Whites).
*  21.8% among those living below the 185% poverty threshold (vs. 14.3% at 400% poverty or higher); and
*  18.8% among adults aged 18 to 39 (vs. 6.5% of those 65 and older). ⁴⁶⁰

cost

• A total of 6.2% of San Mateo County survey respondents report that the cost of health care services has prevented them from seeing a physician at some point in the past year. This includes:

*  47.8% of uninsured respondents (vs. 4.3% of those with private insurance);
*  24.7% of those living below the 185% poverty threshold (vs. 2.7% of those living at 400% poverty or higher);
*  12% of Hispanics and 11.3% of African-Americans (vs. 4.5% of Asians/Pacific Islanders and 4.8% of Whites); and
*  9.8% of those aged 18 to 39 (vs. 4.6% of those 40 to 64 and 0.6% of those 65 and older). ⁴⁶¹

• In addition, 6.3% of survey respondents have needed to purchase a medication in the past year, but could not because of the cost. This increases to:

*  25.9% among those living below the 185% poverty threshold (vs. 3.7% of those living at 400% poverty or higher);
*  25.3% among uninsured respondents (vs. 5.5% of those with private insurance); and
*  7.7% of those aged 18 to 39 and 7.3% of those aged 40 to 64 (vs. 0.5% of those aged 65 and older). ⁴⁶²

lack of transportation

• For 5.6% of San Mateo County survey respondents, lack of transportation has prevented a physician visit at least once in the past year. Lack of transportation has greater impact on:

*  Uninsured persons (13.6% vs. 5.2% of those privately insured);
*  Persons living below the 185% poverty threshold (17.2% vs. 3% of those living at 400% the poverty level or higher);
*  African-American community members (17.2% vs. 4.3% of Whites);
*  Those with a high school education or less (9.3% vs. 4.5% of those with postsecondary education); and
*  Community members aged 18 to 39 (8.5% vs. 2.4% of those 65 and older). ⁴⁶³

language/cultural differences

• A total of 2.3% of San Mateo County survey respondents report that there was a time in the past year when they needed to see a doctor, but could not because of language or cultural differences. By race/ethnic breakout: Hispanics (7.1%); Asians/Pacific Islanders (2.7%); African-Americans (1.1%); Whites (0.9%). ⁴⁶⁴

implications of poor access

Limitations in access have a discernible impact on the health status of county residents and in the way that health care is delivered in the community. Note the following survey findings:

• Uninsured respondents and households living below $28,000 per year more often report "fair" or "poor" health status than do privately insured respondents or those at higher income levels.

*  Less than $28,000 (25.1%) vs. $78,000 and higher (6.4%)
*  Uninsured (13%) vs. Privately Insured (6.6%) ⁴⁶⁵

• Higher "fair/poor" health status is also noted among non-Whites (11.1%): African-Americans (17.1%) and Hispanics (16.4%) in particular, compared to Whites (7.6%) and Asians/Pacific Islanders (4.7%). ⁴⁶⁶

• Uninsured respondents are much less satisfied with the health care they receive (29.6% rate this as "fair/poor") versus privately insured respondents (9.9%). ⁴⁶⁷

For a full demographic and geographic breakout of self-reported health status, refer to the chart on the Personal Health Evaluations page.

• Those without health insurance coverage report the lowest prevalence of preventive health services when compared to privately insured individuals, such as:

  *  Routine check-up in the past year (39.7% versus 72.2% of privately insured)
  *  Dental check-up in the past 6 months (32.9% vs. 71%)
  *  Eye exam in the past two years (30% vs. 73.2%)
  *  Blood pressure testing in the past two years (78.9% vs. 96.3%)
  *  Cholesterol testing in the past five years (49.8% vs. 83.2%)
  *  Know where to access substance abuse treatment (53.5% vs. 70.5%)
  *  Mammogram ever (49.4% vs. 66.2%)
  *  Clinical breast exam ever (88% vs. 98%)
  *  Monthly breast self-exams (34.5% vs. 44%)
  *  Pap Smear test in the past year (57.3% vs. 76.1%)
  *  Prostate specific antigen test ever (13.5% vs. 47.8%)
  *  Monthly testicular self-exam (6.4% vs. 13.6%)
  *  Flu shot in the past year (8.5% vs. 26.4%)
  *  Have sought help for mental health (11.8% vs. 25.6%) ⁴⁶⁸

• A total of 42.3% of uninsured respondents rate access to local health care services as "fair" or "poor," compared to only 12.8% of those privately insured. ⁴⁶⁹

emergency room utilization

• Over one-third of all San Mateo County respondents (34.1%) have used a local emergency room in the past year (average of 1.9 visits). This percentage increases to 50.7% among those living below the 185% poverty threshold. ⁴⁷⁰

• A total of 34.1% of privately insured respondents have visited a local emergency room in the past year, with an average of 1.8 visits each. A higher 38.3% of uninsured respondents have used a local emergency room, also with a higher average of 2.1 visits each. ⁴⁷¹

471   1998 San Mateo County Behavioral Risk Survey. Healthy Community Collaborative of San Mateo County. September 1998.