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Headshot of Jaime Bowman, MD · Vice Chair, Family Medicine
Jaime Bowman
MD · Vice Chair, Family Medicine
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Table of Contents

How to use this material

First, please review this and the optional reading resources completely before your first day on rotation, as they provide important context for connecting with sites and communities. You are welcome to return to this resource throughout the rotation experience to deepen your knowledge and understanding, satisfy your curiosity, or dive deeper into concepts. 

Much of this information clarifies health discrepancy in factual data. This does not accurately reflect that many of these historically marginalized and underserved populations also have strong attributes, key skills, and remarkable capacity. Please consider reviewing these facts using an abundance mindset that acknowledges individual attributes and centers a community’s capacity.

Key definitions

The World Health Organization defines health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”1 Optimal health can be defined as the best possible health for an individual that is free from inequities. In order to understand what inequities means, it is helpful to review two other words commonly used when discussing underserved populations—health disparities and health inequalities.

Disparities
Disparities refer to differences between any two groups.
Inequalities
Inequalities refer to measurements that are unequal when comparing a subgroup of the population with either a reference population (usually the majority) or the population as whole.
When health disparities or inequalities are due to avoidable causes, they are considered inequities. Implicit in the word inequity is the idea that something lacks justice.

An example of a disparity that is not an inequity could be the disease burden of sickle cell disease in black Americans or cystic fibrosis in white Americans. Different populations have different rates of these diseases due to higher prevalence of mutations in the beta hemoglobin and the CTFR genes respectively. These genetic changes likely stem from historical geographic factors and are not due to social and economic factors. These disparities are NOT an indication of biological differences between races. An example of a disease burden that is both a disparity and an inequity is the high rates of HIV seen in people of color in the US compared with the white majority.

Vulnerable populations

When thinking about health, vulnerable is used to describe people who are at risk for poor health outcomes. Almost everyone has some factor that makes them vulnerable to less-than-ideal health. A single vulnerability might not impact an individual’s health, or a single significant vulnerability, such as a genetic predisposition to a disease, could have a large impact on the health of an individual. Increasing vulnerabilities can together contribute to poor health.

Underserved populations

Underserved, by definition, implies a decreased level of service or access to health care. People who are underserved have something that prevents them from accessing quality health care and/or receiving the same quality of health care as people not facing those barriers. Quality health care as defined by the Institute of Medicine (now known as the National Academy of Medicine) is safe, effective, patient-centered, timely, efficient, and equitable.

Access to health care is just one aspect of what contributes to an individual’s health. Limitations in access to care extend beyond obvious causes, such as shortages of health care providers or lack of facilities. Access to health care can be limited by both personal and structural factors—many of these factors are similar to those that can cause an individual to be vulnerable.1, 2 Personal factors are those that cause an individual to decide not to seek care they need (such as cultural differences, language differences, not knowing what to do, or environmental challenges for people with disabilities). Structural factors are those outside an individual’s personal decision making that act as barriers to obtaining the care they need (such as having no health insurance or lacking transportation).

All people who are underserved have at least one vulnerability; many people who are vulnerable are also underserved. While access to care is fundamental to the idea of “underserved” populations, the term has also come to encompass a broader understanding of the limitations of the U.S. health care system. Because underserved populations are so diverse, it is difficult to make generalizations about people who are underserved, or even to discuss the specific history or issues that apply to the underserved. For example, it isn’t entirely clear where “underserved” overlaps with “racial and ethnic disparities.” While there are many intersecting issues (e.g., a patient with health insurance coverage issues may also experience language barriers), there are also situations where the two issues can be seen separately. For example, two insured patients with similar socioeconomic status—one black, one white—are likely to be treated differently and have different health outcomes. The one common thread though, for people who are vulnerable or underserved, is that despite a health care system that spends more than $4 trillion per year3 tens of thousands of patients do not receive quality health care.

A medically underserved area (MUA) is an area with a lack of medical care services as determined by the number of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population 65 years or older.

A Health Professional Shortage Area (HPSA) can be geographic areas, populations, or facilities. These areas have a shortage of primary, dental or mental health care providers.5

Required activity 1 of 4

Please use the Health Data page to explore health information particular to the county you will be in during your Underserved Rotation. What surprised you about the data for your county?

Required activity 2 of 4

Take a minute to complete this Uninsured Quiz from the Kaiser Foundation.

Health Insurance

In the United States, many limits on access to care involve health insurance. Health care in the U.S. is market-based, with individuals most frequently obtaining insurance coverage through their employers. In 2009, the largest underserved population was made up of over 50 million uninsured Americans: 22.5% of all adults under age 65 and 10.4% of all children.7 That rate dropped to 29 million or 9.1% of the population in 2015 because of the Affordable Care Act. For children, it was down to 5.3% in 2015.8

While the majority of Americans obtain health insurance through their employers as a benefit, being employed does not guarantee that an individual or family will have insurance. Many uninsured individuals come from working families with low to moderate incomes, families for whom coverage is not available in the workplace or is unaffordable. Instability in the Insurance marketplace has led to increases in premium costs for consumers, particularly in states without expanded Medicaid. Underinsurance occurs when people have health benefits that do not adequately cover their medical needs. This can occur through high deductible or catastrophic health plans or when coverage does not include needed benefits.

Those without adequate health insurance coverage face barriers to accessing health care, which can ultimately lead to poor health outcomes. Furthermore, those lacking coverage are disproportionately low income and thus, more financially vulnerable. People without health insurance face higher out-of-pocket costs compared to the insured and those with low incomes face larger burdens with medical bills.

Medicare and S-CHIP

Medicare covers most adults aged sixty-five and older. Medicaid and the State Children’s Health Insurance Program (S-CHIP) help provide coverage for millions of low-income people and people with ability limitations that will not reverse.

Under the Affordable Care Act, states were able to expand Medicaid coverage which contributed significantly to the drop in the numbers of uninsured individuals and families.9 In 2015, health expenditures were 1.2 trillion for public (Medicare and Medicaid), 1.1 trillion for private, and 338.1 billion for out of pocket.10 This information could lead to the conclusion that public programs are wasteful compared to private companies but in fact the opposite has been shown to be true. Regression analyses show what variables account for this appearance. Public programs spend more to cover fewer people because those people have a larger disease burden compared to individuals covered by private companies. When spending is adjusted for burden of disease, Medicaid actually spends less per person than private insurance. If all individuals on Medicaid were converted to private insurance, the total health expenditures per person would increase 26% for adults and 37% for children.11

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act is the comprehensive health reform signed into law in March 2010. It aimed to increase the number of Americans with health insurance through an individual mandate (people are required to have health insurance or pay a penalty) while providing access to affordable coverage through a health insurance exchange, cost-sharing credits and subsidies, and the expansion of Medicaid. Legislation enacted in December 2017 effectively repealed that individual mandate, starting in 2019, by making the penalty $0.12

Not all states are moving forward with Medicaid expansion. At this time Washington, Alaska, Montana, and Idaho are the regional states with expanded Medicaid.

Status of State Medicaid Expansion Decisions

Map with the status of state action on Medicaid expansion.13

The S-CHIP and ACA have resulted in a large decline in the proportion of uninsured children, covering 94% of them. Medicaid alone covers 36 million children and CHIP brings insurance to another 8 million whose parents are working with incomes too high to qualify for Medicaid. Many eligible children are not enrolled, whether because of knowledge, access, or immigration status.

Rural communities

In the United States, rural areas include 72% of the land but only 14% of the population. People living in rural areas face a variety of barriers to accessing health care. Although the rural population is almost one-seventh of the US population, only about one tenth of U.S. physicians work in rural areas. As an area becomes more remote, fewer physicians are available for the population living in that area. For example, in urban areas there are approximately 125 physicians per 100,000 people compared to 59 physicians per 100,000 people in rural areas.14 Rural physicians are older than non-rural physicians and impending retirement will aggravate this rural physician shortage. As the number of physicians serving populations goes down, travel time to reach those physicians increases. Furthermore, those living in rural communities in America tend to be older with people aged 65 and older make up 17.5% of rural populations compared with 13.8% of urban populations.15 People in rural areas have lower incomes than their urban counterparts and are less likely to be covered by private insurance. Minority populations are increasing in rural areas and now comprise about 22% of the total rural population.16

Racial and ethnic minorities

Racial and ethnic minorities make up 1/3 of the total population and experience many health disparities compared to white Americans in the United States. Some of these differences can be explained by discrepancies in income and insurance status. However, there is robust evidence that racial and ethnic minorities suffer from worse health outcomes even after accounting for such factors, suggesting that these disparities are racial inequities. A few examples are highlighted below.

  • Black Americans

    Black Americans have the largest number of disparities with higher rates of infant mortality, heart disease, diabetes, and asthma compared to white Americans. Despite similar rates of cancer screening, they are more likely to die of breast, lung, and colon cancer. They are less likely to have received needed diabetes care and more likely to have diabetes related end stage renal disease. They are less likely to be tested for HIV and more likely to be diagnosed with AIDS or to die of HIV. Asthma control is worse with more hospital admissions for exacerbations.

  • American Indian/Alaska Natives

    American Indian/Alaska Natives also have increased rates infant mortality compared to white Americans. They have lower rates of blood pressure and cholesterol screening and are more likely to be diagnosed with AIDS or die of HIV.

  • Latinx

    Compared to white Americans, Latinx are screened less often for cervical and breast cancers and have lower rates of blood pressure and cholesterol screening. Latinx are more likely to have diabetes yet less likely to receive diabetes specific care. They suffer from higher rates of diabetes related end stage renal disease. Like Black Americans and Native Americans, they are less likely to be tested for HIV and more likely to be diagnosed with AIDS or die of HIV-related complications. Asthma control is worse for Latinx reflected by increased rates of hospital admissions for exacerbation.

  • Asian Americans

    Historically, Asian Americans had lower screening rates for cancer. A 2014 study shows that access to primary care and insurance are key and that those who have been in this country for 20 years or more are far more likely to get screening than those who have been here fewer than ten years.17

    NOTE: Disaggregating data can reveal additional disparities that are often overlooked in this larger grouping.

  • All minorities

    Compared to white Americans, all minorities have higher rates of self-reported fair or poor health. All minorities face decreased access to health care compared to white Americans and are more likely to report no usual source of medical care and less frequent dental care. Minority women are more likely to have late or no prenatal care for a pregnancy.18

Other Populations

Many other groups or communities exist that have some vulnerability making them less likely to receive quality health care. These groups include individuals with specific disease states that require specialized care such as those with HIV or substance use. People who face social issues such as homelessness, chronic poverty, or intimate partner violence often require care from multidisciplinary teams to overcome obstacles to improved health. Elders, immigrants, individuals who identify as LGBTQIA+ and people with disabilities may require access to health care providers who have knowledge and skills to address their distinctive needs. Although these groups are heterogeneous in terms of specific characteristics; they share common problems related to access and processes of care. Many also face the intersection of health disparity, trust compromise, and access challenges. 

As always, get curious about the individual and their experiences. Be aware of typical challenges but respect that each person has their own unique life, skills, and challenges. Centering the person first will help you partner to overcome challenges, utilize capacities, and advocate.

Strategies to improve the health of underserved Individuals and communities

Many things can contribute to improving the health of underserved populations and communities. Often this requires an in-depth look at the community or population in order to best determine both its assets and needs, and to strategize on ways to fill in the gaps. A basic knowledge of epidemiology and public health issues is vital to designing and implementing interventions aimed at improving health and reducing inequities. Advocacy for issues surrounding the underserved, be it on a personal, clinic or policy level, is also paramount to affecting change that leads to health equity and social justice.

Some approaches to address health disparities include:

  • Engaging with affected communities to design culturally relevant strategies (community centeredness)
  • Targeted quality improvement strategies
  • Design of health services with a focus on quality
  • Improving integration of public health and clinical medicine
  • Increased patient education and outreach
  • Specific physician communication skills
  • Ensuring access to healthcare services
  • Insurance guarantees
  • Health workforce
  • Increasing the number of minorities practicing in health professions
  • Improving geographical distribution of professionals and facilities
  • Better distribution of specialties
  • Promoting training for health professionals that helps them provide care with cultural humility
  • Ensuring that health care services are provided in a culturally and linguistically sensitive manner.
  • Collecting and disseminating data on the quality of care for racial and ethnic minorities will also help to advocate for effective strategies.

Required activity 3 of 4

Explore the Strategies and Solutions site from County Health Rankings and Roadmaps for evidence-based interventions.19

Unconscious bias in healthcare—physicians are not immune!

All people have unconscious biases. Physicians have a personal responsibility to examine potential biases and prejudices that may affect their communication with and care of patients, and to address them to improve the care they offer. Once understood, continual and intentional engagement in skill development and practice can mitigate the influence of biases on our clinical practice behaviors. Implicit Association Tests are designed to test unconscious bias and can help physicians determine hidden biases and assumptions about particular groups.

Required activity 4 of 4

Explore the Project Implicit website. Select 1–2 implicit association tests to take.

Thoughts to reflect on after taking the test:

    • Did the results surprise you? Did the test seem accurate to you?
    • Did the test make you feel uncomfortable? If so, why? If not, why not?
    • How might these biases show up in your encounters with patients?
    • What could you do to mitigate the effect of your own unconscious biases in your future practice?

Strategies to mitigate bias—what can we do?

Breaking the bias habit:20

  • Recognize, label and challenge stereotypes.
  • Consider the opposite.
  • Identify counter-stereotypes.
  • Individuate and perceive variability.
  • Practice common identity formation.
  • Practice perspective taking.
  • Recite a growth mindset and internal motivational messages.

Safety net

Safety net programs are a critical part of health care in the U.S. and are increasingly essential to assuring access to health services for uninsured and other underserved populations. Federally Qualified Health Centers (FQHCs) are clinics governed by a board of directors that provide primary care for people of all ages, usually based on a sliding scale fee for uninsured patients. In addition to enhanced Medicare and Medicaid reimbursement, the FQHC designation gives these clinics federal grant support, malpractice coverage, and access to free vaccines and reduced cost medications. FQHCs include Community Health Centers (CHCs), Migrant Health Centers, Health Care for the Homeless Programs (HCH), and Public Housing Primary Care Programs. Rural Health Clinics (RHCs) are another type of federally funded clinic that are located in a rural location and require incorporation of mid-level providers to meet primary care needs of a population.21

There are many different types of safety net providers in addition to federally funded programs, including free clinics, county services and hospitals, and public health clinics. Various factors influence the extent to which access is actually increased by these clinics or programs, including provider capacity and funding available to provide care. Many physicians in private practice informally provide charity care for patients who are otherwise unable to finance care.

Conclusions and take-home concepts

Because many factors contribute to optimal health there are many ways that people can be vulnerable to poor health outcomes. When these vulnerabilities affect access to quality health care an individual is considered underserved. Almost 20% of the US population is uninsured, almost 20% of the population lives in rural areas and a third of the population is a racial or ethnic minority. This means that many people living in this country grapple with what it means to be underserved and therefore, most physicians and healthcare professionals will work with vulnerable and underserved patients.

Adequate access to quality care (including trust development) is one crucial aspect in reducing health inequities and increasing the quality and years of healthy life for all persons in the United States. Working towards social equity in other arenas is also needed if we are to improve the health of all and decrease health disparities.

Resources

Optional additional reading

Related resources for students who want to delve further:

 

Additional optional content is available on the course page.

References

Adapted in part from UW Underserved Pathways Module.

  1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
  2. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001. 337p. 
  3. Center for Medicare & Medicaid Services, Research, Statistics, Data & Systems. National Health Expenditure Data Fact Sheet: NHE Fact Sheet [Internet]. Baltimore (MD): US Center for Medicare & Medicaid Services. [Updated 2021, Dec 15]. 
  4. Bay Area Regional Health Inequities Initiative. Framework. [Internet]. Oakland (CA): A Public Health Framework for Reducing Health Inequities. 
  5. Health Resources & Services Administration. Workforce Shortage Areas, What is Shortage Designation? [Internet]. Rockville (MD): US Department of Health and Human Services, HRSA. [cited 2022 Apr 24].
  6. KFF: Filling the need for trusted information on national health issues [Internet]. San Francisco (CA). KFF; Uninsured quiz; 2015 Nov 19. [cited 2022 Apr 24]. 
  7. US Census Bureau. Current Population Reports: Income, Poverty, and Health Insurance Coverage in the United States: 2007. Table 149.
  8. US Census Bureau. Income, Poverty and Health Insurance Coverage in the United States: September 2016.
  9. Guth, M, Garfield, R, Rudowitz, R. The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020. KFF, 2020 Mar 17. [Cited 2022 Apr 24]. 
  10. Center for Medicaid and Medicare Services. [Internet]. Highlights of National Medical Expenditure Data 2015. [cited 2022 Apr 24]. (PDF.)
  11. Health Affairs, 27, no. 2 (2008): w318-w333.
  12. Fiedler, M. The ACA’s Individual Mandate In Retrospect: What Did It Do, And Where Do We Go From Here? Health Affairs [Internet]. 2020 Mar [cited 2022 Apr 24]; 39 (3).
  13. KFF: Filling the need for trusted information on national health issues [Internet]. San Francisco (CA). KFF; Status of State Medicaid Expansion Decisions: Interactive Map. 2022, Apr [cited 2022 May 16]. 
  14. Machado, S, Jayawardana, S, Mossialos, E, et al. Physician Density by Specialty Type in Urban and Rural Counties in the US, 2010 to 2017. JAMA Network Open. 2021;4(1)e2033994: doi:10.1001/jamanetworkopen.2020.33994
  15. The US Census Bureau. [Internet]. The Older Population in Rural America: 2012–2016. 2019,Sept. 23. [Updated 2021, Oct. 8]. [cited 2022, May 16]. 
  16. Dobis, E., (2021, Nov. 18) Rural America at a Glance [webinar]. USDA.gov webinar series. 
  17. Lee, S, Chen, Lu, Jung, M, Baezzconde-Garbanati, L, Juon, S. Acculturation and Cancer Screening among Asian Americans: Role of Health Insurance and Having a Regular Physician. Journal of Community Health. 2014 Apr; 39(2): 201-212. doi: 1007/s10900-013-9763-0
  18. HJ Kaiser Family Foundation. Key Facts: Race, Ethnicity and Medical Care, 2016 Update.
  19. County Health Rankings & Roadmaps.[Internet]. University of Wisconsin Population Health Institute. Take Action to Improve Health. [Cited 2022, May 16]. 
  20. Carnes M, Devine PG, Baier Manwell L, et al..The Effect of an Intervention to Break the. Gender Bias Habit for Faculty at One Institution. Academic Medicine 2015; 90 (2): 221-230. Doi: 1097/ ACM.0000000000000552.
  21. Werner, C. Key Differences between FQHCs and RHCs. Medical Billing & Collections, Practice. Models, Physicians Practice. [Internet]. 2013 June 12. 

Image credits

Unless otherwise noted, images are from Adobe Stock.