elderly in United Stated as a vulnerable population

SPECIAL FEATURES: HEALTH POLICY

Improving Access to Health Care for Uninsured Elderly Patients Shalonda Horton and ReginaJ.Johnson

ABSTRACT The purpose of this article is to explore the barriers that the uninsured elderly population encounter when accessing health care in the United States. These barriers include, but are not limited to lack of transportation, insurance, or family support; the daunting complexity of the health care system; poverty; culture; poor patient-health care provider communications; race/ethnicity; and lack of health care professionals such as nurses and doctors with adequate geriatric preparation, or generalists who are un- dereducated in geriatrics. The number of health care professionals currently available to treat elderly persons in the United States is inadequate. The Federal government should take steps to develop solutions to improve access to health care and decrease health disparities for older adults. As a nation, we should be proactive in addressing these concerns instead of waiting for new barriers to arise that further limit access to health care for elderly patients and their families. In this article, we provide an assessment of the barriers that limit access to health care in the uninsured elderly population and suggest recommendations and possible solutions to eliminate or reduce these barriers.

Key words: access to health care, barriers to health care, uninsured elderly.

Although high-quality health care is generally avail- able in the United States, elderly Americans die from preventable diseases and illnesses every day because various barriers block their access to health care. Ac- cording to the American Nurses Association [ANA] (2007), the ‘‘Medicare and Medicaid programs were enacted in 1965 to fill two of the most gaping holes in the health care system by providing coverage for those over 65 . . . and for a large segment of the poor’’ (p. 1). The elderly are generally considered those over age 65. In 2006, nearly 37.3 million people in the United States were age 65 or older, representing 12.4% of the U.S. population (U.S. Department of Health and Human Services [USDHHS], Administra-

tion on Aging, 2007). This number is expected to double from 2010 to 2030 to 72 million or 20% of the U.S. population (He, Sengupta, Velkoff, & DeBar- ros, 2005; USDHHS, Administration on Aging, 2007). The overall health of the elderly is improving with de- clining death rates from heart disease and decreasing disability rates. Still, 80% of people over age 65 have at least one chronic medical condition (He et al., 2005).

From the perspective of the profession of nursing, one of the four most critical essentials of health care reform include access to health care (ANA, 2008). The Centers for Disease Control and Prevention [CDC] (2005) emphasized that improving health care for the elderly will require culturally appropriate public health initiatives, community support, and equitable access to quality health care. If we do not take steps to break down these barriers now, it could mean higher health care costs and further social injustices in the future (CDC). Access to health care is one of the Healthy People 2010 leading indicators. Strong pre- dictors of access to quality health care include having health insurance, a higher income level, and a regular primary care provider or other source of ongoing health care (USDHHS, 2000).

Shalonda Horton, M.S.N., R.N., is Clinical Instructor, School of Nursing, The University of Texas at Austin, Austin,Texas. Regina J. Johnson, Dr. P.H., M.S.N., R.N., is Associate Professor,School of Nursing,The University of Texas at Austin, Austin,Texas. Correspondence to: Shalonda Horton, School of Nursing,The University of Texas at Austin, 1700 Red River Street, Austin, TX 78701-1499. E-mail: [email protected]

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Current barriers to accessing health care include lack of transportation, insurance, or family support; the daunting complexity of the health care system; poverty; culture; poor patient-health care provider communica- tion; and race/ethnicity. Other barriers that may affect health care for the elderly include lack of health care professionals such as nurses or doctors with adequate geriatric preparation. By addressing each of these bar- riers, we hope to improve awareness and stimulate the proposal of creative solutions that will begin to break down these barriers in the near future. In this article, we provide an assessment of the barriers that limit ac- cess to health care for the uninsured elderly and suggest recommendations and solutions to meet the Healthy People 2010 goals (USDHHS, 2000).

Lack of Transportation

About 20 million U.S. drivers are age 65 or older, which is expected to double by 2020 (Merck & Co. Inc., 2000). As drivers age, they are more at risk for functional deficits (Merck & Co. Inc., 2000), which may cause the elderly to avoid driving. Nonetheless, they still require transportation to and from health care appointments. Lack of transportation hinders many elderly adults from obtaining timely and appro- priate health care. Fitzpatrick, Powe, Cooper, Ives, and Robbins (2004) reported that 21.1% of elderly participants in their study had transportation issues trying to access health care. To understand the strug- gles encountered by elderly patients lacking transpor- tation better, we rode the public transportation system in a major U.S. city to the nearest health cen- ter that provided care for patients without insurance. After walking 0.7 miles and riding a bus for 2 hr (one way), we discovered that using such public transpor- tation requires reasonable physical fitness, compe- tence to follow bus route directions, and ability to endure long rides and bus transfers. Some cities have programs or charities that provide transportation for elderly residents, but not all older adults meet the qualification criteria, and those in rural areas may lack these services altogether.

Those who have health insurance also perceived transportation as a barrier to receiving health care. Stuber and Bradley (2005) reported that 34% of Med- icaid recipients had difficulties finding transportation to obtain health care services and 27% of those inter- viewed thought that office hours for medical care were often prohibitive. Furthermore, 65% of the rural

counties in America are experiencing shortages of health care professionals, which is yet another barrier to accessing health care for the elderly (Probst, Moore, & Glover, 2004).

Lack of Insurance

Health insurance provides access to health care. Not having insurance often inhibits elderly persons from seeking medical attention, putting them at a higher risk for social isolation and lack of access to health care. In 2004, the number of people living in the United States without health insurance was 45.8 mil- lion or 15.7% of the population; only 40 million were uninsured in 2003 (Denavas-Walt, Proctor, & Lee, 2005). In 2003–2004, 0.8% of adults over age 65 were uninsured.

Compounding the problem is the number of el- derly adults who are underinsured. The underinsured elderly are those who have private or government- sponsored health insurance, but the associated out- of-pocket medical expenditures and health plan deductibles exceed their ability to pay (Schoen, Doty, Collins, & Holmgren, 2005). A study of insured adults in 2003 revealed that 15.6 million or 12% were under- insured (Schoen et al., 2005); 13% of these were age 50–64. Fitzpatrick et al. (2004) found that out-of- pocket expenses were the greatest financial burden for Medicare recipients. In 2003, 40% of adults age 65 and older spent more than US$1,000 per year on out- of-pocket medical expenses compared with only 12% of adults age 18–44 (National Center for Health Sta- tistics [NCHS], 2006). Paying out of pocket for med- ical services may not be an option for many elderly citizens, who live on fixed and low incomes.

Similarly, elderly adults with insurance may delay seeking medical attention or obtaining prescription drugs because of the financial burden (Fitzpatrick et al., 2004; NCHS, 2006). Niefeld and Kasper (2005) evaluated access to health care services in an elderly population with substantial needs for medical and long-term care services. An access barrier was defined as ‘‘failure to obtain, or difficulty obtaining, a service that is needed’’ (p. 302). Their study indicated that racial disparities in access persisted among elderly people with comprehensive coverage for a wide range of services, including nonmedical long-term care ser- vices. Results also indicated that organizational and geographic barriers to receiving care disproportion- ately affected elderly African Americans.

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Complexity of the Health Care System

Another barrier for the elderly is difficulty in access- ing and navigating the health care system, especially government health care plans, which are often con- fusing (Kuttner, 1999). A study conducted with Med- icaid recipients revealed that many lacked critical knowledge of Medicaid program rules (Stuber & Bradley, 2005). In addition, 48% of recipients felt that the Medicaid application was unduly long and complicated, and simply obtaining the application and other documentation was a major challenge.

Capitated payment systems have forced health care providers to explore new methods of care deliv- ery for the elderly population who consume a dispro- portionate amount of time and resources (Nelson & Arnold-Powers, 2001). Nelson and Arnold-Powers (2001) conducted a qualitative study with 11 partici- pants (8 women, 3 men) to describe the experiences of elders in a community case management program within a managed care setting. The common threads among the participants included changes to the health care plan, concerns about the health care system gen- erally, impersonal service, system navigation, and loss of control. For example, some participants discussed their feelings regarding the change from a nonman- aged health care delivery system to a managed care senior plan. Many of the participants felt that ‘‘the new managed care senior plan created feelings of frustration and resignation’’ (Nelson & Arnold-Pow- ers, 2001, p. 446). In addition, they spoke of several areas of difficulty, frustration, despair, and loss of control over their health care decisions in relation to their health care delivery system.

For several months in 2007, we attempted to locate insurance information for the uninsured (i.e., Medicaid and Medicare), understand eligibility crite- ria, and determine the steps that must be taken to apply and qualify for these health plans. We found that the system in Central Texas was complex and difficult to navigate. For example, after several tele- phone calls over a week’s time, and long waiting times on the telephone, we were able to obtain an eligibility appointment for a health insurance coverage program in our area. Through research and interviews, we learned that if uninsured persons have all the needed documents, they might receive their eligibility card for health care services on the same day. However, the next available appointment for new patients may be

3–4 months from the time of enrollment, despite the patient having only 6 months of health care coverage.

The multiple rules and paperwork for various health insurance programs are, by all accounts, con- fusing and complicated. Those with little education might consider this process intimidating and perceive it as a barrier. For this reason, education level often affects access to health care services. For example, el- derly patients who are unable to read would have problems understanding patient education informa- tion, and understanding and completing application forms. According to Probst et al. (2004), more than 75% of elderly African Americans and Latinos do not have a high school diploma. In addition, elderly pa- tients often have limited vision due to age progression or other health conditions, making it difficult to read materials.

Poverty

Poverty often limits access to health care by prevent- ing the elderly from seeking care for financial reasons. In 2004, 37 million people in the United States were living in poverty; 3.5 million or 9.8% of these were elderly (Denavas-Walt et al., 2005). In one study, elderly adults who earned less than US$12,000 per year were 2.6 times more likely to report barriers to accessing health care than those earning US$50,000 or more per year (Fitzpatrick et al., 2004). In 2003, 23.7% of African Americans age 65 and older lived be- low the poverty level, compared with 8.8% of Cauca- sians, 14.3% of Asians, and 19.5% of Hispanics in the same age group (USDHHS, Administration on Aging, 2004). ‘‘Low income populations are at risk for ad- verse health outcomes and yet have little or no access to a regular source of heath care’’ (National Associa- tion of Community Health Centers Inc., 2005, p. 2). Because of cost, poor elderly adults are less likely to obtain medical care than the younger population.

Not all elderly adults qualify for health insurance coverage sponsored by the government, like Medicare and Medicaid. Medicare is a health insurance pro- gram for those age 65 and older, those under age 65 with certain disabilities, or those of any age with end- stage renal disease (USDHHS, Centers for Medicare & Medicaid Services, 2008). Medicaid is a state-admin- istered program designed to help pay health care ex- penses for people with low incomes. Each state has its own set of guidelines and eligibility rules (USDHHS, Centers for Medicare & Medicaid Services, 2006).

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Although these programs are available and often help- ful, a portion of the elderly population does not meet the eligibility criteria; thus, they are uninsured or un- derinsured. In addition, if a recipient earns more than the low-income eligibility criteria, they will not be eligible for Medicaid either. According to the NCHS (2006), even those elderly who qualify for Medicaid or private health insurance may have difficulty access- ing health care; in 2003–2004, 27% of physicians reported that they did not accept new Medicaid pa- tients and 41% did not accept new privately insured patients.

Lack of Family Support

Some elderly adults do not have family or friends for emotional, physical, or financial support, which may put them at a higher risk for social isolation and inad- equate access to health care. In addition, as adults age, activity level can become limited, which may de- crease their ability to interact with others in society and thus negatively affect their quality of life (NCHS, 2005).

Elderly patients who live alone or do not have family available to assist them must be competent to arrange their own medical appointments, manage their own health care, and organize their own trans- portation. A lack of telephone services may also in- crease isolation and access to health care. Isolation can also be created within the health care system it- self. For example, many elderly adults have perceived a lack of support or responsiveness from the health care system. In a study by Fitzpatrick et al. (2004), the most common barrier to accessing health care en- countered by the elderly was their perceptions that their doctors’ lacked responsiveness to their concerns.

Culture

Culture is a learned set of values and beliefs passed from one generation to another (Ting-Toomey & Oetzel, 2001). Culture is probably not a direct barrier to health care, but it may indirectly affect access to health care. A person’s belief system may influence his or her decision to seek medical treatment. In addition, some patients and families exercise cultural practices to treat some health conditions. Astin, Pelletier, Ma- rie, and Haskell (2000) reported that many U.S. adults use home remedies and/or alternative or non- traditional therapies. Forty-one percent of the elderly

population uses some type of alternative therapy (As- tin et al., 2000). For example, in a study by Easom and Quinn (2006), 26% of caregivers used apple vin- egar as a home remedy to lose weight; 11% used a honey, lemon, and whiskey mixture to treat cold symptoms; and 6.25% used wild garlic to lower cho- lesterol and prevent cancer. Buono, Urciuoli, Mari- etta, Padoani, and De Leo (2001) reported that the elderly might use home remedies because of the diffi- culty in accessing advice from health specialists.

Kemp (2005) and Huff and Kline (1999) de- scribed how Latino, Asian American, and African American families sometimes use home remedies and lay healers for treating illnesses. For example, herbs and spiritual or traditional rituals may be used to treat certain health problems. Culture may also in- fluence an individual’s decision to seek medical care (Huff & Kline, 1999). These cultural examples are not meant to be stereotypical, but to illustrate the cultural diversity in our society.

If health care providers are not sensitive to the diverse cultures represented in their practice, they may create a barrier that prevents elderly patients and their families from accessing health care. Further- more, if health care providers are not respectful of the diverse cultures they encounter, patients and their families may self-treat or seek care from nonmedical professionals, which can be dangerous or even life threatening for those with serious illnesses.

Communication

In conjunction with culture, communication heavily influences uninsured elderly adults and their family’s access to health care programs. For example, some patients and families who we interviewed were not aware of existing programs and services available for the uninsured or they did not know where to begin searching. Johnson, Roter, Powe, and Cooper (2004) indicated that physicians tended to be less patient- centered when communicating with African American patients compared with Caucasian patients. If a health care provider is an ineffective communicator and a breakdown occurs in patient communication, the es- tablishment of trust among the patient, family mem- bers, and the health care provider is hindered.

Effective communication between health care providers and patients may enhance patient and fam- ily education, treatment adherence, and health out- comes (Johnson et al., 2004). Quality health care

Horton and Johnson: Access to Health Care for Uninsured Elderly 365

communication is critical to patient and family edu- cation, participation, and the promotion of healthy lifestyle behaviors (Kreps, 2006). Communication is critical to reduce health disparities and increase the patient’s trust of the health care system and his or her health care provider. For example, because cancer rates are significantly higher among African Americans compared with those of other ethnicities, effective health communication can improve cancer- related health outcomes. Effective communication improves cancer outcomes by enabling primary, sec- ondary, and tertiary prevention strategies to be im- plemented. According to Kreps, culturally tailored cancer awareness campaigns have positively influ- enced African Americans’ prevention and screening behaviors. In addition, using familiar and trustworthy communication channels, such as local radio and tele- vision programs and church, school, or work organi- zations known by the population, have been effective in cancer outreach campaigns. Therefore, when health care providers and community organizations use their caring interpersonal communication skills tailored to a population, such as African Americans, cancer inci- dence, morbidity, and morality rates decrease along with health disparities (Kreps, 2006).

Race/Ethnicity

Race and ethnicity may create barriers to receiving health care. Racial and ethnic disparities in access to health care coverage have been widely documented. For example, Cornelius and Smith (2002) found that women of color perceived discrimination as a barrier to receiving preventive care. Race and ethnicity are also associated with health disparities because minor- ities are at a greater risk for illness than the majority of the U.S. population (Smedley, Stith, & Nelson, 2003; Villarruel, 2004). Sometimes, a minority popu- lation’s health needs go unaddressed by health care providers because of a lack of knowledge of the health disparities in that particular population, which may lead to a lack of trust in the health care system gener- ally, creating yet another barrier to health care access. Smedley et al. (2003) suggested that evidence showed that bias, prejudice, and stereotyping by health care providers might contribute to the differences in care in racial and ethnic minorities.

Ageism is another barrier that may affect access to health care. In a study by McGuire, Klein, and Chen (2008), ageism was frequently reported, suggesting

that ageism was flourishing in the United States and may have a negative effect on longevity and healthy aging. The elderly population will be more racially and ethnically diverse in the future (He et al., 2005). The proportions of African Americans, Asians, and His- panics in the U.S. population will all increase in the next several decades, with elderly Hispanics almost quadrupling between 2003 and 2030, from two to nearly eight million (Walsh, Currier, Shah, Lyness, & Friedman, 2008).

Because of health disparities, some diseases are more prevalent in some populations than in others. For example, the African American population ‘‘bears a disproportionate burden of disease, injury, death, and disability’’ (CDC, 2005). More deaths were re- ported in 2000 for African Americans age 65–84 from heart disease, malignant neoplasms, and cerebrovas- cular disease than in any other ethnicity (He et al., 2005). Hebert, Frick, Kane, and McBean (2005) found that far fewer elderly African Americans and Hispanics received the influenza vaccination than el- derly Caucasians.

Recommendations and Possible Solutions

Medicine and technology have significantly advanced in recent years, which has led to a better quality of health overall; however, older adults within our com- munities often do not have equal access to health care services, which may lead to a lack of prevention or a greater risk that health problems go untreated. As our society ages, more medical services will be required from a system that is already resource limited. The effects of the barriers that limit access to health care, along with the rising costs of health care, cannot be ignored much longer (Strunk, Ginsburg, & Gabel, 2002). Out-of-pocket expenditures are often detri- mental to elderly adults who are living on fixed or limited incomes. If health care and sociodemographic trends are not appreciated, the crisis of elderly pa- tients requiring access to health care will be realized through inadequate treatment options and less effec- tive and efficient delivery of services.

In the future, the expected growth rate of the el- derly population is likely to heavily burden the health care system and further limit access to needed ser- vices. To circumvent a future with even more elderly adults without access to health care, the Federal gov- ernment would be wise to quickly and proactively

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address the barriers to health care, including the lack of transportation, insurance, and family support; the complexity of the health care system; and issues re- lated to poverty, culture, communication, and race/ ethnicity. As a nation, it is unrealistic to think that we can break down these barriers overnight; rather, the long-term solution is to implement multiple interven- tions and policies to address the barriers directly.

Improve health insurance coverage One way to prepare for rising health care costs and the potential increase in the number of uninsured elderly adults is to focus on health insurance coverage (Lillie- Blanton & Hoffman, 2005). Having a reliable source of care and health insurance are important to the elderly remaining healthy and reducing health dispar- ities (DeVoe, Fryer, Phillips, & Green, 2003; Lillie- Blanton & Hoffman, 2005). Reforming the current health care system will not only decrease the number of uninsured elderly, but will also decrease the num- ber of uninsured in the United States overall. One way to deter costs and improve access to health care is the implementation of universal health care coverage. The 1994 Clinton Health Care Plan was defeated by Con- gress, but it is time to begin thinking ‘‘outside of the box’’ again and put aside political differences. The United States should implement universal health care insurance alongside an effective health care delivery system (Fryer et al., 2003; Kronick, 2005; Schroeder, 2001; Starfield, 2005).

Universal health insurance has the potential to diminish the complexity of the current health care system. For example, rules from multiple health care programs would no longer govern the system, but there would be one common set of rules, which would decrease the daunting complexity of the system. In addition, adopting universal health insurance cover- age would increase the number of patients serviced by each health care provider.

Case management model of care Another way to address the complexity of the current public health care system would be to assign case managers to uninsured patients for the first 6 months after they enter the system. Case managers would ed- ucate elderly patients on how to successfully navigate the system, thus ensuring continuity of care and de- creasing the chances that they get lost in the system. Introducing case managers into the system would cer- tainly be costly; however, the cost of emergency room

visits by uninsured elderly adults who have difficulty in navigating the current system is even higher. Assigning case managers and implementing early preventive public health measures would be more cost-beneficial than the current system (Nelson & Arnold-Powers, 2001).

Outreach services If cost remains an issue in the future, the government could collaborate with community organizations and volunteers to provide outreach services that help the uninsured elderly complete the massive paperwork required to qualify for insurance coverage. Several foundations and nonprofit organizations already sponsor community outreach projects that strive to promote the well-being of their community, such as the Robert Wood Johnson Foundation and the Dell Foundation, to name a few. Eldercare in Ontario, Can- ada, is an example of a publicly funded program that is mandated to facilitate access to community care services and act as a single-entry point to community care for elder services (Brotman, 2003).

Capacity within faith-based organizations (FBOs) could also be built. Some FBOs, such as churches, perform outreach and health promotion services as part of their mission. FBOs have the potential to im- prove quality of life and access to health care for many groups, but they also help sustain long-term support needed by the elderly (DeHaven, Hunter, Wilder, Walton, & Berry, 2004). Ensuring that all patients have fair health care services, regardless of socioeco- nomic status, race/ethnicity, or cultural background, would also serve to diminish the barriers to health care encountered by the elderly.

Cultural competency and communication Another recommendation is that health care provid- ers attend cultural competency training programs, co- ordinate with traditional community healers, collaborate with community health workers, and/or include families as active members in the patient’s plan of care and health care decisions (Brach & Fraserirector, 2000). These steps would create an en- vironment of trust and partnership between patients and health care providers.

Campinha-Bacote (2003) illustrated how the Process of Cultural Competence in the Delivery of Healthcare Services Model and the LEARN Model might serve as tools for health care providers to ex- amine their own cultural background and enhance

Horton and Johnson: Access to Health Care for Uninsured Elderly 367

their cultural competence. The models help health care providers become aware of their cultural biases and prejudices and may decrease the chances of bias when providing care to elderly patients. When health care providers are culturally competent, health dis- parities are reduced (Rust et al., 2006).

In addition to cultural competence, effective two- way communication between health care providers and elderly patients is essential to a trusting relation- ship. A health care provider who completes cultural competency training may also learn techniques for effectively communicating with members of various cultural groups. The relationship among health care providers, patients, and families may influence racial health disparities (Saha, Arbelaez, & Cooper, 2003). Communication that demonstrates an appreciation for a patient’s culture, and using culturally appropri- ate patient/family health education materials, are now a necessity (Campinha-Bacote, 2003; Freimuth & Quinn, 2004; Kreps, 2006).

Now, and in the future, the health care system and its providers should take the lead in supporting culturally sensitive health education in print, audiovi- sual, and Internet-based materials (Kreps, 2006). Computer-based patient education can also serve as an interactive and creative communication tool for el- derly patients and their families (Kreps, 2006). One way to improve patient and family awareness of avail- able health care programs for the uninsured is to ad- vertise them via the media (e.g., radio, television, newspaper, and neighborhood association newslet- ters). Billboards and advertisements in public trans- portation (e.g., buses, trains), pharmacies, grocery stores, malls, senior community centers, and libraries are other ways to increase awareness about available health care programs.

Improve transportation Mobile units (i.e., buses or vans) that go out into the community to reach older adults without transporta- tion would also improve access to health care. Taking health care directly to the community is not a new concept; in 1893, Lillian Wald, the first public health nurse, specialized in preventative health care and went door to door serving those in need. Some com- munities use a similar model of community outreach to provide immunizations to children, which could be adopted to provide health care services to the elderly in rural areas or inner cities. Mobile services might include public health prevention campaigns, patient

education, disease management, case management, and health insurance enrollment. To assist those with transportation, outpatient clinics should open earlier and close later to better accommodate low socioeco- nomic status communities. Implementing these changes would provide patients and their families greater access to health care, reducing emergency room visits and expenses.

In closing, additional research is needed that spe- cifically addresses the growing population of elderly adults and their future health care needs, as well as resources, health disparities, and access to health care. As the elderly population continues to increase, the barriers to accessing health care will have a detri- mental effect on the health care industry. The barri- ers, such as lack of transportation, insurance, and family support; complexity of the health care system; poverty; culture; communication; and race/ethnicity, must be addressed. The lack of health care profes- sionals such as nurses, doctors, or inadequately pre- pared geriatric professionals must also be tackled if health care for the elderly will be improved. In turn, health disparities will begin to decrease. As a nation, we must be proactive in addressing the barriers that prevent access to health care by the elderly before new barriers arise that further limits access to health care for the uninsured and underinsured elderly.

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