Of Privilege and Percentage: A Reflection on Access

Jeff Bontrager

July 9, 2019
Access to Care
Care Delivery

On a scale of one to 10, how would you rate your ability to get the health care you need?

I’d probably give my own ability a 9.5 out of 10. I have good health insurance and easy access to care. And most of my friends and family do too; I’ve been pleasantly surprised at the relative ease with which my aging parents have been able to get the primary and specialty care they need.

But allow me a moment to check my privilege.

I’m a person who identifies as white, able-bodied, male, English-speaking, without children, in relatively good health and with stable employer-based coverage who can afford the copays and deductibles. I have reliable transportation to travel the 10 minutes it takes to get to my doctor, and I have an employer that is flexible with time off for appointments. I don’t have to worry about finding a provider who understands me or my health needs. And I never have a nagging question about whether I’m not receiving quality care because of my race, gender, or ability.

But I know that others have a different experience of the health care system. I hear about the challenges from acquaintances, in my research, in the news, and from others in my community.

And therein lies the story of CHI’s newest Access to Care Index. The index is an interactive tool that synthesizes different data points that can be used to examine dimensions of access to care around the state.

Our synthesis of 27 metrics suggests that most Coloradans have decent access to the care that they need. If you dig deeper, however, the story becomes more nuanced.

We know that having coverage greatly increases the likelihood you’ll get needed care. But it’s not a guarantee. So we decided to look more closely at what’s happening among Coloradans with two different types of coverage: commercial insurance and coverage through Health First Colorado, our state’s Medicaid program.

Any comparison between Medicaid and other groups needs to take into account that Medicaid members — by virtue of the fact that eligibility for most members is based on having a low income — face compounded barriers associated with making ends meet. We discuss this issue in greater depth in the brief.

But we know there are evolving challenges for people in both of these groups that are worth examining in depth. One only has to click on a news site to read about increasing costs among privately insured people, especially in the state’s rural areas. And now that one in five Coloradans are covered by Medicaid, we wondered if the conditions were in place to ensure timely access to care for so many residents.

What did we find?

Despite the relatively high score of 7.4 out of 10, Medicaid members face greater access barriers than Coloradans with commercial insurance almost across the board. For example, a higher percentage of Medicaid members report they didn’t get an appointment because a provider was not accepting new patients (19% vs 7%), didn’t obtain needed breast cancer screening (63% vs 42%), or were able to afford dental care (18% vs 11%). 

There are a few exceptions and limitations: CHI estimates a much higher percentage of eligible Coloradans are enrolled in Medicaid (92%) when compared to those eligible for tax credits through Connect for Health Colorado, the state’s health insurance marketplace (43%). A greater percentage of Medicaid members with persistent asthma received appropriate prescription medication (91%) compared to commercially insured Coloradans (84%).

But the data in the index can also be applied to answer a variety of questions. CHI designed the Access to Care Index to enable multiple types of comparison:

  • Geographic comparisons. The index contains scores for all of Colorado’s 64 counties and the state overall. We often hear concerns that adjacent counties are lumped together when they have very different population sizes and demographics. Think Boulder and Weld, La Plata and Archuleta, Mesa and Garfield. Users now have the ability to go beyond the regional view and pull the data for counties with similar characteristics.
  • Payer comparisons. These comparisons don’t just focus on deficits — such as the gap between penetration rates mentioned above — but on similarities, where barriers carry across the two payers. For example, the rate of colorectal and breast cancer screening shows room for improvement for Coloradans enrolled in Medicaid and those with commercial insurance.
  • Comparisons across domains. CHI grouped the 27 indicators into three equal buckets: Potential Access, Perceptions and Experiences, and Realized Access. Scores in the second domain — which includes indicators describing people’s experience in trying to obtain care — are higher than scores for Realized Access — obtaining needed services. This suggests that while fewer Coloradans may be facing logistical barriers, that doesn’t always translate into the use of services.

While a few of the metrics in the index are displayed over time, we don’t have the full Medicaid and Commercially Insured indexes available for past years. But you can contact CHI at info@coloradohealthinstitute.org for more detail about how a particular metric has changed over time. You can also find many data points in past Colorado Health Access Survey (CHAS) reports and workbooks.

Finally, the index is intended to complement other forthcoming analyses and tools:

  • CHI will release hot-off-the-press findings from the 2019 CHAS in September 2019.
  • The Colorado Department of Health Care Policy and Financing will release its second federally mandated Access Monitoring Review Plan — which all states must complete to help ensure that Medicaid members’ access to services is comparable to other types of coverage — in October 2019.
  • CHI also will release a deep dive into access for one particular category of services — specialty care. The analysis measures unmet demand for specialty care among Medicaid members and Coloradans without insurance compared to those with commercial coverage.

Obtaining the appropriate care at the right time at the right place is complicated. And it’s even more complicated to measure. When I reflect on my almost 15 years at CHI, it strikes me that there is so much more focus on access to needed care than there used to be — and that there are future directions we hope to explore, such as access to non-medical resources such as housing, food security, and transportation.

For now, however, we anticipate that this year's Access to Care Index will be a useful tool for informing the discussion about how to ensure all Coloradans have the opportunity to be as healthy as possible.

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