Suicide and homicide are violent actions reported in the news daily.  Individuals suffering from abuse, depression, mental disorders, or substance-abuse disorders are at an increased risk for committing suicide or homicide.  Factors that contribute to the risk are age, gender, socio-economic status, and race/ethnicity. Additionally, situations that cause extreme life or job stress, such as those seen when a loved one dies or by military personnel, can contribute to the risk.  Chapter 6 attach highlights barriers to care relating to the vulnerable and this population group in particular.  For this discussion:

1)  Locate and share statistical data for your community on annual suicide and homicide rates.

2)  Identify and briefly describe one organizational barrier and one financial barrier relating to the suicide- and homicide-prone.

3)  Create two recommendations on ways each of these barriers can be reduced or eliminated.

4)  Identify two local resources available for suicide- or homicide-prone individuals. 

 Discuss which services are offered and whether the services fully meet the needs of the population.

Your initial contribution should be 250 to 300 words in length.

Due 2/5/20 @1pm Eastern

6

Accessing Health Care

Learning Objectives

After reading this chapter, you should be able to:

• Identify where access barriers originate.

• Examine the organizational barriers to accessing health services as experienced by
vulnerable populations.

• Explain the financial barriers to accessing health services as experienced by vulnerable
populations.

• Consider ways to improve access to health care.

• Explain the politico-social forces affecting access to health care.

Courtesy of Beerkoff/Fotolia

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CHAPTER 6

Self-Check

Answer the following questions to the best of your ability.

1. Which populations face access barriers to health care in both financial and orga-
nizational forms?

a. vulnerable
b. naturalized citizens
c. employed
d. school-age children

Critical Thinking

The text states, “More physicians abandon small private practices in favor of joining large health care
conglomerates.” Do you think that these larger corporations would be more willing to accept Medicaid
patients and thus increase accessibility?

Introduction

Introduction

Though institutionalized racial segregation ended decades ago, many would argue that Americans continue to be segregated by
socioeconomic class. Economic status determines
where people live and attend school, and even
where they go to the doctor. Vulnerable popula-
tions face access barriers to health care in both
financial and organizational forms. For example,
many physicians do not accept patients on Med-
icaid, and many who do limit the number to a
certain percentage of their practices or a certain
number of appointments per week. This creates
an organizational barrier to health care access for
Medicaid recipients. At the same time, many low-
income people struggle to find the money to pay
for services that aren’t covered by Medicaid or the
co-pays on the services covered by their employ-
ers’ insurance, thereby creating a financial barrier
to access. As more physicians abandon small pri-
vate practices in favor of joining large health care
conglomerates where they can improve reim-
bursement rates and lower malpractice insurance
rates, and more people receive Medicaid or Medi-
care, reliable access for the vulnerable becomes
increasingly tenuous.

Courtesy of Sheri Armstrong/Fotolia

Though a patient may be covered by
Medicaid, many are unable to take full
advantage of that coverage because of
physician-imposed limits and restrictions.

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CHAPTER 6Section

6.1 Organizational Barriers

2. Many physicians limit the number of what types of patients to a certain percentage
of their practices or to a certain number of appointments per week?

a. HIV/AIDS
b. elderly
c. those on Medicaid
d. charitable cases

3. Many low-income people struggle to find the money to pay for what services
covered by their employers’ insurance?

a. enrollment fees
b. wage taxes
c. political contributions
d. co-pays at medical facilities

Answer Key

1. a 2. c 3. d

6.1 Organizational Barriers

Organizational barriers to health care access for America’s most vulnerable include health care deserts with a limited number of health care locations in poor, urban areas; understaffed health care offices in vulnerable areas that are unable to meet
the needs of the number of patients in the area; cultural gaps between providers and
patients in low-income regions; and fear. Fear, in fact, creates a two-sided access bar-
rier. On the provider side, many practitioners choose not to locate their practices in poor
regions for fear for the safety of the staff, fear of lawsuits from socioeconomically dis-
advantaged individuals seeking to take advantage of physicians’ malpractice insurance,
and fear of financial hardship caused by too many patients who cannot pay their medical
bills. On the patient side, fear creates an access barrier due to fear of an inability to pay for
services, fear of intrusion into their lives, and fear of a health care delivery system that is
populated by practitioners who cannot relate to vulnerable patients’ struggles. Each vul-
nerable population experiences organizational barriers to access differently; these varied
experiences will be explored in greater detail in the next few sections.

Vulnerable Mothers and Children

The effects of organizational barriers for high-risk mothers and babies begin before con-
ception. Many women do not receive gynecological care—medical care specializing in the
female reproductive system—from their family doctors. This means that many women,
regardless of socioeconomic class, must act as an informational go-between among their
multiple medical providers, carrying test results between doctors’ offices and remember-
ing to provide complete medical histories from memory. Without electronic health
records, which store a patient’s health data in a digital database that is accessible by all of
a patient’s authorized providers, the delivery system for women’s health care remains
disjointed and difficult to maneuver. Vulnerable mothers often lack access to appropriate
gynecological care and reproductive health counseling, which increases the risk of

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CHAPTER 6Section 6.1 Organizational Barriers

unplanned pregnancies. They often seek prenatal care later in their pregnancies than those
with stronger support systems. Many women with incomes below 200% of the federal
poverty level report not seeking health care due to an inability to take off work during
clinic hours. Others report that physical access to health care is restricted because they
lack transportation to get to doctors’ offices (Ranji & Salganicoff, 2011).

Many of the organizational bar-
riers to accessing health care
faced by women can be miti-
gated by extending clinic hours
and locating services along
public transportation routes
and in low-income urban and
rural areas. Unfortunately,
national trends have been in
the opposite direction. Instead
of locating their offices in low-
income areas, many physicians
are moving out of them (U.S.
Health Resources and Services
Administration, 2012).

The number of doctors who
treat pregnant women for preg-
nancy, called obstetricians, is
also diminishing. Those who
remain increasingly give up
small, independent practices in
favor of joining large for-profit

health care conglomerates. By doing so, they are able to minimize malpractice insurance
premiums and their individual liability (U.S. Health Resources and Services Administra-
tion, 2012). Many of the large hospitals that do provide obstetric care are located in more
affluent areas, where private payers and patients are better able to pay higher fees for
medical care. This, of course, creates an organizational barrier for vulnerable mothers,
who must find appropriate transportation to access these areas.

Abused Individuals

Organizational barriers to health care for abused individuals reside in a fragmented treat-
ment system that includes a menagerie of medical and mental therapies, as well as inter-
vention from social services and the criminal justice system. Law enforcement, educators,
and doctors are often the first reporters of domestic abuse of women and children (Child
Welfare Information Gateway, 2012). Their reports of suspected abuse are made to gov-
ernment social services agencies including Child Protective Services (CPS). Once a report
is made, social workers investigate, and if severe abuse or neglect is present, the process
of removing the victims from the home and the rehabilitation of families begins. A break-
down in the reporting process occurs when school and medical center staff are poorly
trained in recognizing the symptoms of abuse and have reservations about the ramifica-
tions of reporting suspected abuse.

Courtesy of Kati Molin/Fotolia

Many women with incomes below the poverty level are not
able to seek health care because of an inability to leave work
during regular clinic hours.

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CHAPTER 6Section 6.1 Organizational Barriers

Adult victims of domestic violence can be more difficult to remove from an abusive situ-
ation than are children. Legally, CPS social workers can remove a child from an abusive
situation if they deem it to be necessary. However, social workers from agencies like Adult
Protective Services (APS) cannot forcibly remove an adult who does not want to leave or
declines to leave for fear of retribution from the abuser. The criminal justice system gets
involved in punishing offenders of child, intimate partner, and elder abuse and is often
the only line of defense for an adult victim of domestic violence. This does not necessarily
mean that reported offenders are arrested or jailed. The criminal justice system also facili-
tates restraining orders and orders of protection.

Among the community organizations and government departments that address domes-
tic violence, there is little overlap and partnership in programming, as independently
involved organizations often focus on different aspects of the abuse. For example, many
programs that exist for treating child victims of abuse do not address the needs of the
adults in the relationship. Most battered women shelters will accept children, although
having children may alter a woman’s ability to remain at the shelter due to shelter rules
about the length of time a child may be housed or individual childcare issues such as
keeping the children in their enrolled schools. More cooperation is needed between the
disassociated agencies that are in place to address the needs of abused individuals.

Chronically Ill and Disabled Persons

Organizational barriers for chronically ill and disabled individuals revolve around physi-
cal access to programs and providers, as well as program eligibility requirements and an
uncoordinated selection of programs.

People with mobility problems
may have difficulty simply get-
ting to treatment centers. This is
particularly true for low-income
disabled and chronically ill
patients who statistically lack
social capital, which can be
thought of as the number of
relationships a person has and/
or the number of social net-
works a person belongs to, all
of which provide resources and
support. For example, a person
in an advanced stage of multiple
sclerosis (MS) may have diffi-
culty walking without the use of
a cane. This may mean that he
or she can only access doctor’s
offices that have parking struc-
tures within reasonable walking
distances. Additionally, without
a friend or relative who can help navigate the walk from the parking structure to the
office, he or she may find the trip too arduous to complete on his or her own.

Courtesy of Getty Images/Thinkstock

Often, treatment is hindered for people with mobility problems
due to an inability or difficulty in getting to treatment centers.

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CHAPTER 6Section 6.1 Organizational Barriers

Even when an individual is eligible for particular programs—whether that be caretaker
respite programs, meal delivery programs, home visits, and transportation services—
these programs may not be available in his or her area. Often, coordination is lacking when
services are available, which creates a barrier to access. Individual community programs
and government programs operate independently, and each often has its own focus. For
example, a meal delivery program may not offer caretaker respite. In these situations, it
is up to the individual person to find available resources and enroll in needed programs.

Persons Diagnosed With HIV/AIDS

HIV/AIDS patients face organizational barriers to health care access in many differ-
ent forms. Limited space is designated in long-term centers specifically for HIV/AIDS
patients; staff is sometimes undertrained in HIV/AIDS care; some medical staff may pur-
posefully limit their contact with HIV/AIDS patients for fear of contracting the disease or
for other personal reasons; and the sparse number of community support services is often
underfunded and has long waiting lists. Ways of counteracting these barriers include
improved staff training on the history, or pathology, of HIV/AIDS; its epidemiology,

which refers to the distribution and prevalence
of disease in a population; and best practices for
HIV/AIDS–related patient care.

Improved financial access to antiretroviral
drugs would continue to lower the number of
HIV/AIDS patients in need of long-term care,
and improved funding for community-based
resources would help shorten waiting lists. One
of the most important public health initiatives
to have been enacted in recent years is the fed-
erally funded Ryan White Comprehensive AIDS
Resources Emergency (CARE) Act program,
which works to improve access to health care
and community resources for low-income HIV/
AIDS patients. The act provides grants and addi-
tional funding to secure the success of HIV/
AIDS treatment and prevention programs in
underserved areas. (For more information on the
community-based and health care organization–
based resources supported by the CARE Act, visit
http://hab.hrsa.gov/.)

Improved access to general care providers and
preventive counseling among those most at risk
for contracting HIV would work to lower the
number of new infections. Among homeless intra-
venous drug abusers, access to preventive care
and treatments is severely limited. Without func-

tional inpatient care, homeless and intravenous drug abusers who have HIV/AIDS find it
difficult to maintain treatment compliance, as physical and financial access barriers make
it difficult to obtain medication and maintain treatments plans.

Courtesy of Minerva Studio/Fotolia

Inadequate staff training and lack of
funds can prevent HIV/AIDS patients from
receiving proper care.

Courtesy of WavebreakmediaMicro /Fotolia

Thorazine was used to treat mentally ill
patients before antipsychotic drugs were
available.

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http://hab.hrsa.gov/

CHAPTER 6Section 6.1 Organizational Barriers

Persons Diagnosed With Mental Conditions

Before the first antipsychotic drug, Thorazine, was used to treat mentally ill patients,
America’s most severely mentally ill were regularly housed in government-run institu-
tions (Torrey, 1997). Ten years after Thorazine
became common in psychological therapy, Med-
icaid was created to improve health care access
for low-income individuals. The combination of
these two events, in tandem with a shift in social
ideology regarding forced institutionalization and
involuntary care, created an atmosphere wherein
physicians were encouraged to deinstitutionalize
mental health care for the most severely affected.
By the 1990s, most of America’s long-term care
facilities for the severely mentally ill were no lon-
ger in service. Now, the onus of inpatient care
of severely mentally ill patients rests on nursing
care facilities, the criminal justice system, and
the diminished number of specialized long-term
inpatient care centers that treat mental illness.

Housing is perhaps the most pressing health care
access problem for individuals with severe men-
tal conditions. Without proper housing, they are
liable to suffer the myriad negative health out-
comes of homelessness. Some of these patients
also end up in the criminal justice system, where
their health care access is limited by the institu-
tion (U.S. Bureau of Justice Statistics, 2006). Out-
comes are improved for those patients who live
with their families, but access is often limited to
community resources for the caregivers of men-
tally ill patients. If there is a lack of community resources, the strain on caregivers may be
overwhelming; as a result, patients may end up having to leave their homes. More fund-
ing for community support programs and resource organizations like the National Alli-
ance for the Mentally Ill (NAMI) may lead to increased access and improved outcomes.
Many of these same support programs can also help create positive outcomes for people
with mental conditions who live independently, in board and care homes, group homes,
and veterans’ housing.

The Surgeon General’s 1999 report on mental health in the United States reflected that
social attitudes that encourage a microlevel personal view of mental health that put all the
responsibility of care on the individual negatively affect funding proposals that would
support mental health services (National Institute of Health, 1999). Legislation increasing
financial support of mental health programs, and increasing coverage for mental health
therapies, could change social opinions and raise awareness of the existence of a vulner-
able population living with mental conditions. Resourcing staff who once worked in long-
term care institutions for the mentally disturbed to train new staff in community-based
programs would increase those programs’ ability to effectively help psychiatric patients
(Koyanagi & Bazelon, 2007).

Even when an individual is eligible for particular programs—whether that be caretaker
respite programs, meal delivery programs, home visits, and transportation services—
these programs may not be available in his or her area. Often, coordination is lacking when
services are available, which creates a barrier to access. Individual community programs
and government programs operate independently, and each often has its own focus. For
example, a meal delivery program may not offer caretaker respite. In these situations, it
is up to the individual person to find available resources and enroll in needed programs.
Persons Diagnosed With HIV/AIDS
HIV/AIDS patients face organizational barriers to health care access in many differ-
ent forms. Limited space is designated in long-term centers specifically for HIV/AIDS
patients; staff is sometimes undertrained in HIV/AIDS care; some medical staff may pur-
posefully limit their contact with HIV/AIDS patients for fear of contracting the disease or
for other personal reasons; and the sparse number of community support services is often
underfunded and has long waiting lists. Ways of counteracting these barriers include
improved staff training on the history, or pathology, of HIV/AIDS; its epidemiology,
which refers to the distribution and prevalence
of disease in a population; and best practices for
HIV/AIDS–related patient care.
Improved financial access to antiretroviral
drugs would continue to lower the number of
HIV/AIDS patients in need of long-term care,
and improved funding for community-based
resources would help shorten waiting lists. One
of the most important public health initiatives
to have been enacted in recent years is the fed-
erally funded Ryan White Comprehensive AIDS
Resources Emergency (CARE) Act program,
which works to improve access to health care
and community resources for low-income HIV/
AIDS patients. The act provides grants and addi-
tional funding to secure the success of HIV/
AIDS treatment and prevention programs in
underserved areas. (For more information on the
community-based and health care organization–
based resources supported by the CARE Act, visit
http://hab.hrsa.gov/.)
Improved access to general care providers and
preventive counseling among those most at risk
for contracting HIV would work to lower the
number of new infections. Among homeless intra-
venous drug abusers, access to preventive care
and treatments is severely limited. Without func-
tional inpatient care, homeless and intravenous drug abusers who have HIV/AIDS find it
difficult to maintain treatment compliance, as physical and financial access barriers make
it difficult to obtain medication and maintain treatments plans.
Courtesy of Minerva Studio/Fotolia
Inadequate staff training and lack of
funds can prevent HIV/AIDS patients from
receiving proper care.
Courtesy of WavebreakmediaMicro /Fotolia
Thorazine was used to treat mentally ill
patients before antipsychotic drugs were
available.

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http://hab.hrsa.gov/

CHAPTER 6Section 6.1 Organizational Barriers

Suicide- and Homicide-Liable Persons

Suicidal and homicidal behaviors stem from a mix of mental health problems and
socioeconomic inequality. As such, the programs in place that work to lower suicide and
homicide rates are uncoordinated. Programs on violence prevention exist in the fields
of physical health, mental health, community-based support programs, education, social
services, criminal justice, and public health and wellness. Initiatives range from suicide
hotlines to school assemblies about violence prevention to support group therapies.

The federal initiative, Public Health Objectives for the Nation, 2020 (PHON), addresses
suicide and homicide by working to reduce the following (U.S. Healthy People, 2012):

• suicide rate
• number of adolescent suicide attempts
• number of people experiencing major depressive episodes in both adolescent

and adult categories

PHON attempts to meet these goals by doing the following:

• increasing the number of primary care facilities offering mental health treatment
services

• improving access to mental health services for children
• increasing screening for mental health problems in juvenile residential facilities
• increasing depression screening in primary care settings
• improving treatment methods for people with both mental health disorders and

substance abuse behaviors

Although clinical interventions are important for treating individual patients, community
interventions have a greater effect on homicide and suicide rates on a macro level. One of
PHON’s community intervention plans is an initiative to improve programs and access
to those programs for treating patients who have suffered traumatic events. Improved
training for hospital social workers, emergency room staff, physicians, and educators will
increase the recognition of adults and youth who are prone to violence or are subjected to
violence, and get them into prevention programs faster. Improving local economies and
living conditions in low-income areas may also reduce the overall number of attempted
homicides and suicides by reducing stress on the people who populate those areas.

Persons Affected by Alcohol and Substance Abuse

Alcohol and substance dependence has both physiological and psychological compo-
nents. Physiological dependence on a substance is evidenced primarily by the develop-
ment of physical symptoms (withdrawal symptoms) when the substance is no longer
consumed. Psychological dependence, on the other hand, manifests as a desire, or “crav-
ing,” for a substance. Although effective treatment for alcohol and substance abuse must
address both the physiological and psychological aspects of a person’s addiction, some
treatment programs address only one or the other. This means that patients are sometimes
forced to coordinate two kinds of care in order to address their chemical dependencies. In
some circumstances, both physiological and psychological therapies are offered in tandem

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CHAPTER 6Section 6.1 Organizational Barriers

under the umbrella of one provider
organization. Many patients are
under treatment as mandated by
social services or the criminal jus-
tice system. These patients often
lack the means to seek out the
best possible treatment options for
their particular circumstances, and
instead receive the minimum man-
dated care.

Alcohol and substance abuse pro-
grams are improved by increasing
awareness of the socioeconomic
struggles that lead to higher drug
abuse rates in some communities.
Culturally sensitive treatments use
cultural components, like religion
and cultural-based social norms,
to encourage and empower the
patient to continue treatment and

make the necessary physical and emotional changes that can keep them from relapsing.
Treatment centers can also reduce organizational barriers by hiring bilingual staff and
locating in underserved areas.

Indigent and Homeless Persons

Homeless individuals are far more
likely to lack a regular family doc-
tor. Many avoid seeking care unless
absolutely necessary. When medi-
cal care does become an immediate
need, homeless persons without a
regular physician often end up at
urgent care centers and hospital
emergency rooms. Social attitudes
about homeless people often lead
to their being met with negativity
and hostility. Many homeless peo-
ple report being sent away from
some medical care clinics to seek
treatment elsewhere. Transporta-
tion difficulties make it difficult
for this vulnerable population to
move from clinic to clinic seeking
medical treatment.

Courtesy of Brand X Pictures/Thinkstock

Between 2009 to 2010, a lack of health care and increasing
rates of reckless behavior have raised demand for
emergency food assistance by nearly 24%.

Courtesy of Jochen Sands/Thinkstock

Many alcohol and substance abuse programs do not
holistically treat the patient, instead addressing either only
the psychological symptoms or only the physical symptoms.

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CHAPTER 6Section 6.1 Organizational Barriers

Critical Thinking

Many vulnerable patients have a “fear of a health care delivery system that is populated by practitioners
who cannot relate to vulnerable patients’ struggles.” How do you interpret this statement? How might
a practitioner overcome this fear?

Financial barriers, social stigmas, and physical access barriers like limited transportation
lead to an exacerbated health deficit for America’s homeless. Increased rates of unpro-
tected sex, drug abuse, and HIV, combined with a lack of regular health care, have caused
America’s homeless numbers to strain the support system that is in place to address their
needs. The U. S. Conference of Mayors’ 2010 Hunger and Homelessness Survey reported
that demand for emergency food assistance increased almost 24% from 2009 to 2010. May-
ors reported that increasing the availability of affordable housing topped their initiatives
lists as a means to mitigate a growing homeless population. Unemployment was the most
cited cause of homelessness for family units. Together, increasing employment opportuni-
ties and affordable housing offer a macrolevel solution to reducing the number of Amer-
ica’s homeless and to reducing the need for medical care among this population. Fewer
homeless puts less strain on the health care delivery system and may increase access to
those still homeless by having a smaller pool of people who rely on the already small pool
of funds for emergency care of the homeless.

Immigrants and Refugees

Naturalized citizens face fewer organizational access barriers than undocumented immi-
grants and refugees. Many refugees live in government-subsidized housing. Others may
live in areas that are more densely populated with other immigrants. Physicians’ offices
and other medical clinics are often sparse in these areas. In some cases, medical providers
have the legal right to request proof of legal immigration before seeing patients. Many
undocumented immigrants avoid seeking medical care for fear of deportation.

Immigrants and refugees also face language barriers and cultural barriers to accessing
health care. Medical providers can limit these barriers by hiring bilingual staff and train-
ing staff to understand and meet the needs of their patients based on cultural ideals and
norms. For example, a physician’s office that treats a significant number of Muslim fami-
lies should be familiar with acceptable behaviors related to the body, such as rules con-
cerning clothing and disrobing in front of a person of the opposite gender, as dictated
by the religion of Islam. Other cultural barriers involve differences in how health and
well-being are defined. Cultural acceptance is fundamental to providing quality care to
immigrant populations.

Self-Check
Answer the following questions to the best of your ability.

1. Authorized providers can access a patient’s health data ______.
a. on the Internet
b. in electronic health records

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CHAPTER 6Section

6.2 Financial Barriers

c. in a centrally located records department
d. in a warehouse in Washington, DC

2. Many of the support services available to disabled people are delivered through
what type of programs?

a. Veteran’s Affairs
b. Medicaid
c. community
d. state department

3. Currently, which entities are responsible for inpatient care of severely mentally ill
patients?

a. nursing care facilities
b. private homes
c. local businesses
d. professional organizations

Answer Key

1. b 2. c 3. a

6.2 Financial Barriers

The United States spends more on health care per capita than any other nation, and health care costs are still rising across the globe. This is partially due to America’s free market economy, which avoids regulating industry as much as possible. It is
also because America is a forerunner
in the development and adoption of
new medical technologies and phar-
maceuticals. New technologies and
drugs cost more than older ones
because the manufacturers price
them high to help recoup the costs
associated with research, develop-
ment, and federal safety approval.

Most insurance plans include co-
pays, deductibles, and cost shar-
ing. These patient charges result
in decreased financial accessibility
to medical care, even for patients
with private payer insurance. As
it is difficult for patients to know
what their out-of-pocket expenses
will be for many tests and proce-
dures done in physician offices,
many people avoid health care treat-
ments as much as possible. In some

Courtesy of George Doyle/Thinkstock

Deregulation of the industry and the rapid development
of new medical technologies and pharmaceuticals have
resulted in the United States spending more on health care
per capita than any other nation.

bur25613_06_c06_173-194.indd 183 11/26/12 2:49 PM

CHAPTER 6Section 6.2 Financial Barriers

circumstances, patients are subject to blood tests and other procedures without an oppor-
tunity to consider the costs before they are administered. Imagine the shock of one patient
who received a bill for $7,000 for a DNA test that was not covered by insurance and was
done at the same time that blood was drawn for routine annual blood work.

Both public and private payers limit the amount of coverage per patient. Medicaid nego-
tiates lower reimbursement rates for physicians. Because of this, many physicians maxi-
mize the percentage of clientele with private payer insurance because private payers have
higher reimbursement rates. This practice, based on financial decisions, leads to organi-
zational barriers to care when Medicaid and uninsured patients cannot find doctors and
medical clinics that will treat them.

Vulnerable Mothers and Children

Prenatal care is expensive, partially due to the cost
of treatment, and partially due to high liability
insurance premiums that obstetricians must pay
to avoid financial ruin from malpractice lawsuits.
When doctors pay high insurance premiums, that
cost is reflected in what they charge patients for
care.

In 2009, 22.3% of women of childbearing age
(women in the age range of highest fertility, which
is 15 to 44) had no insurance coverage of any type.
This was an 11% increase from that of 2008 (March
of Dimes Foundation, 2010). Uninsured women
are significantly less likely to seek early prenatal
care because the cost of prenatal care is so high.
Medicaid patients are a bit more likely to seek
care earlier in their pregnancies; however, many
women eligible for Medicaid during pregnancy
do not get through the application process until
later in the gestational period (March of Dimes
Foundation, 2010).

For those who do have Medicaid coverage, find-
ing an obstetrician who accepts Medicaid patients
is increasingly difficult. Progress has been made
to reach out to obstetricians by increasing Medic-
aid reimbursements to incentivize them to accept
Medicaid patients. With a dwindling number of practicing obstetricians, many uninsured
and Medicaid-covered pregnant women seek prenatal care at local health departments,
where their care is often uncoordinated.

Courtesy of Carlos Santa Maria/Fotolia

In 2009, almost 25% of women of
childbearing age were without insurance
coverage.

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CHAPTER 6Section 6.2 Financial Barriers
Abused Individuals

It is argued that the social services departments that handle domestic abuse are under-
funded and understaffed. Community programs that help abused women escape bad
situations often rely on grants and individual donations. These programs are nearly non-
existent for male victims of domestic abuse. Males do not report the abuse for a number
of reasons; hence, a program for males will not be fruitful until reducing the stigma of
male reporting becomes a public health goal. Individual financial barriers exist in many
abusive relationships where the victim is dependent on the offender for financial security,
housing, and insurance coverage. This dependence makes it difficult for a victim to leave
or improve an abusive situation. Shelters and other programs do exist to help battered
women with housing and with finding work at little or no charge.

Chronically Ill and Disabled Persons

Chronically ill and disabled people have expensive, ongoing health care needs. Lifetime
caps on insurance benefits, cost sharing between insurance companies and patients, and
patient co-pays can all add up to large out-of-pocket costs for this vulnerable population.

The Medicare SSDI program for
disabled people who are unable
to work has a two-year waiting
period, though eligible people
can apply for welfare and Med-
icaid in the meantime (U.S.
Social Security Administration,
2012c). The first few years of a
chronic condition or disability
are often the most expensive in
terms of health care needs. For
the uninsured, this two-year
waiting period can lead to two
years’ worth of unpaid medical
bills. Those with private payer
insurance may reach their life-
time coverage limits and essen-
tially lose their private payer
coverage while they apply for
Medicaid and wait for Medi-
care SSDI eligibility. Preexist-
ing condition clauses in health

insurance policies enable insurance companies to refuse coverage for many of America’s
chronically ill and disabled people, but SSDI does not have preexisting condition clauses
as it is designed to help these very people.

Medicare and Medicaid do cover some long-term treatments, such as nursing home care
and physical rehabilitation services. However, coverage is restrictive and based on a myr-
iad of factors, including the chances of positive outcomes from the treatments and patient
ability to cover some or all of the costs. Medicare will only cover long-term care for a

Courtesy of Tatiana Belova/Fotolia

The cost of treating a long-term illness is often highest in the
first two years, during which time disabled people who are
unable to work must wait before receiving Medicare SSDI
benefits.

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CHAPTER 6Section 6.2 Financial Barriers

maximum of 120 days, if the patient is making marked recovery or rehabilitative strides
toward some end goal. At that point, Medicaid may pick up caring for the patient if they
have less than $2,000 in total assets and make less than 133% of the poverty amount for
an individual. Managed care plans and health care coordinators help limit costs by coor-
dinating care across multiple disciplines (physical therapy, home visits by nurses, and so
on) and negotiating better fees for both payers and patients alike.

Persons Diagnosed With HIV/AIDS

Financial barriers to health care access for HIV/AIDS patients are rooted in cost of care
and social stigma. As HIV/AIDS drug therapies continue to improve, patients are living
longer, which increases their lifetime cost of care for HIV/AIDS treatments. New improve-
ments in treatment therapies are expensive because pharmaceutical companies price new
drugs high to recoup research and development expenses. High prices and increased lon-
gevity lead to increased out-of-pocket expenses for HIV/AIDS patients. Early detection is
essential, as many patients die within two years of the onset of AIDS without antiretrovi-
ral therapy. Early treatment can also help reduce the cost of medical care by slowing the
progression of the symptoms of both the primary and related illnesses.

Social stigma surrounding the HIV/AIDS epidemic has led to lax regulation of insurance
coverage for HIV/AIDS patients. Many private payer insurance contracts allow for pre-
approval testing for HIV. Still others allow for immediate cancellation of the policy if a
patient becomes HIV positive. Many states allow insurers to discriminate based on sexual
orientation, and thereby limit the number of HIV positive patients in the insurance pool.
HIV/AIDS patients with public payer coverage often find that Medicare and Medicaid
coverage for HIV/AIDS–related treatments is minimal.

Persons Diagnosed With Mental Conditions

Though federal health care laws do address the problem, there is still a parity gap between
mental health treatment coverage and treatment coverage for physical health. This means
that mental health services are not as available as physical health services, both in terms
of geographic proximity to patients and in the ability of the existing mental health services
delivery system to meet demand. Similarly, an equity gap also exists between mental
and physical health services. This essentially means that patients who can afford better
insurance coverage and higher out-of-pocket expenses have better access to mental health
services than do those who cannot afford them. Medicaid does provide mental health
benefits for qualifying patients, under which they can sometimes get more services, lon-
ger treatment duration, and good treatment from masters-level professionals—which is
usually the requirement. The Patient Protection and Affordability Act of 2010 (PPACA)
addresses mental health parity by expanding the applicability of federal mental health
parity laws and mandating coverage for specified mental health and substance abuse
recovery treatments (National Conference of State Legislatures [NCSL], 2011).

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CHAPTER 6Section 6.2 Financial Barriers

Both public and private payer coverage is usually less for mental health services than for
other services. Many plans include annual maximums in number of treatments and cov-
ered treatment costs with some federal- and state-mandated exceptions. Many also have
higher out-of-pocket expenses for patients, which means that the insurer pays less of the
total cost for mental health services than most do for physical health services. Medicaid in
most states pays providers significantly less for mental health services than it does to
physical health service providers. This has led to mental health professionals limiting the
number of Medicaid patients they will accept.

Suicide- and Homicide-
Liable Persons

Violence prevention programs
are historically underfunded and
plagued by delivery problems.
These programs work to pre-
vent violence through social and
economic investments in under-
served, low-income communities
and in individuals. A significant
number of these programs are
community-based and are finan-
cially dependent on private dona-
tions and grants. Many health
care trauma centers that once
attempted to serve low-income
areas were put out of business
in part by the increasing costs of
treating victims of violence who
were unable to pay for their care.
As Chapter 7 illustrates, studies
have found that violence prevention programs cost hospitals and trauma centers signifi-
cantly less than does treating victims of violence.

Persons Affected by Alcohol and Substance Abuse

A significant disparity exists between alcohol and substance abuse treatments available
to patients with private payer insurance and those with public payer insurance. Provid-
ers in the private sector earn more revenue while treating fewer patients. Though private
payers limit the amount of coverage for substance abuse therapies, particularly inpatient
treatments, patients with private payer coverage are better able to afford the out-of-pocket
costs and, as such, demand higher-quality treatments.

Courtesy of powerofforever/iStockphoto

Violence prevention programs work to prevent violence
through social and economic investments in underserved,
low-income communities and in individuals.

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CHAPTER 6Section 6.2 Financial Barriers

A benefit of these upscale treatment facilities is that many offer coordinated treatments,
including both physical and mental health services, all under one roof. While private payer
patients “recuperate” in these facilities, they often enjoy more comfortable accommoda-
tions than are available in institutions that serve public payer patients. In fact, many public
payer substance abuse patients receive treatment under compulsory terms, meaning they
are forced into treatment by social services or the court. While courts and social services
are forcing people into substance abuse programs, welfare reformers have been cutting
funding and eligibility for substance abuse coverage under Medicaid. The results of these
cuts are that felons who are convicted of drug charges are not eligible for substance abuse
program coverage in many states (when living outside of jails and prisons). This has par-
ticularly affected pregnant women who are addicted to alcohol and other drugs. However,
some amount of treatment is available to jailed offenders. The Federal Bureau of Prisons
has strengthened its substance abuse treatment programs in an effort to reduce relapse,
improve convicts’ abilities to rejoin society, and improve the safety and social atmosphere
inside penitentiaries (U.S. Department of Justice, Federal Bureau of Prisons, 2012).

Indigent and Homeless Persons

Most homeless people do not have any type of health insurance, and even those with
insurance often cannot afford to pay their share of the cost of health services. Many differ-
ent state and federal agencies (for example, Department of Health and Human Services
and Department of Veterans’ Affairs) have programs in place to address the problem of
homelessness and the needs of homeless people. Some of these departments offer grants
to community-based services and health care clinics and professionals who are willing to
treat indigent people as a significant portion of their client base.

Many of these funding opportunities are administered under the Stewart B. McKinney
Homeless Assistance Act of 1987, which specifically recognized the need for federal
monies to address homelessness and the needs of this population. Since 1987, many
agencies have had the designated funding for homeless programming cut, and recipient
programs often lament the fact that the grant approval processes are unduly long and
difficult to navigate.

Immigrants and Refugees

Financial access to health care for immigrants is similar to that of other groups in the
United States. However, some immigrant and refugee members of the population encoun-
ter barriers to accessing public payer insurance because legislation like the Welfare Reform
Act of 1996 decreased eligibility for nonnaturalized citizens. Undocumented immigrants
have no access to public payer health care insurance in most states. Naturalized immi-
grants and those who qualify for public payer and private payer insurance generally have
the same financial benefits and restrictions as other subscribers.

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CHAPTER 6Section 6.2 Financial Barriers
Critical Thinking

Health care tests and procedures are often performed without consulting patients on the costs and finan-
cial liabilities until after they have been rendered. Do you think it would be better if patients understood
costs before services are rendered, or do you think discussing costs should be of secondary importance
to the patients’ health? What do you think would be the result if health care providers were suddenly
required to have patients sign off on the cost of each individual procedure before being rendered?

Self-Check
Answer the following questions to the best of your ability.

1. What programs are nearly nonexistent for male victims of domestic abuse?
a. community support
b. federal programs
c. faith-based services
d. public transportation to and from work

2. Many states allow insurers to discriminate against individuals on the basis of
_____________________.

a. a preexisting condition
b. pregnancy
c. sexual orientation
d. immigration status

3. The Federal Bureau of Prisons has strengthened its substance abuse treatment
programs in an effort to reduce what?

a. occupancy
b. in-prison drug use
c. fetal alcohol syndrome births
d. relapse

Answer Key

1. a 2. c 3. d

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CHAPTER 6Section 6.2 Financial Barriers

Case Study: Patient Profiling and Inequalities in Care as Organizational Barriers

Susan was a 22-year-old Caucasian female who worked at a coffee shop.
She did not have health insurance through work and had never consid-
ered checking for Medicaid eligibility. Susan and her boyfriend regularly
used illicit substances, including crack, cocaine, and marijuana.

When Susan became pregnant, she sought prenatal care at a local health
department. Health department staff helped Susan sign up for Medicaid,
and she continued with regular prenatal care at that facility. During one
appointment in the third trimester, Susan’s doctor asked her if she ever
had or currently used illicit drugs. Susan replied honestly and told her
doctor that she had stopped using most drugs when she learned she was
pregnant, though she continued to smoke marijuana and cigarettes on a
regular basis. Susan later reported that the doctor nodded, took notes,
and never counseled Susan on the negative effects of the use of those
substances during pregnancy or offered cessation help.

Weeks later, Susan gave birth to a full-term baby girl. The next morning,
a physician she had never met before entered her hospital room with a
social services worker. They told Susan that the doctor who had treated
her at the health department throughout her pregnancy had reported
Susan’s drug use to social services. They had already drawn blood from
the baby to test for drug dependence, and Susan would be hearing from
social services with the test results. They warned that if the baby tested
positive, they were prepared to remove the infant from her mother’s
care. Either way, Susan and the baby would be working with social ser-
vices for the next year, or until their assigned social worker determined
that there was no danger to either the mother or child.

After two worry-filled days, the social worker arrived unannounced at Susan’s door. The baby had tested
negative for everything and was deemed to be in good health. After six months working with her social
worker, Susan was removed from the social services program after many follow-up visits and multiple
negative drug tests.

Susan reported feeling singled out by the doctors and social services and felt that she was punished
for her honesty. Her basis for feeling singled out was that a friend of hers was simultaneously pregnant
and had private payer health insurance. The friend reported never having been asked about cigarette,
alcohol, or substance use or abuse history by any of her physicians or hospital staff.

Part of the difference in their experiences was simply that they had different doctors. But the friend had
a physician in an office that specializes in obstetric care for women with private payer insurance. It may
be that Susan was profiled because she received her prenatal care at the public health department.

Courtesy of Stockphoto4u/
iStockphoto

Susan abused drugs
before and during her
pregnancy and was
threatened with the
possibility of giving
up her baby to social
services.

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CHAPTER 6Self-Check

Self-Check
Answer the following questions to the best of your ability.

1. Among PHON’s community interventions plan is an initiative to eliminate
programs and access to those programs for treating patients who have suffered
traumatic events.

a. True
b. False

2. The U.S. Conference of Mayors’ 2010 Hunger and Homelessness Survey reported
that demand for emergency food assistance increased how much from 2009 to
2010?

a. 4%
b. 13%
c. 24%
d. 42%

3. Cultural acceptance is fundamental to providing quality care to which
populations?

a. religious
b. immigrant
c. minority
d. pregnant female

Chapter Summary

Organizational and financial barriers to health care are intertwined. These barriers range from the physical location of health care providers to providers’ reluctance to treat patients who have difficulty paying for treatment. Legislation that limits cov-
erage eligibility and increases the ability of insurance companies and medical providers to
deny coverage and care creates organizational barriers for both private payer and public
payer patients. Some organizational barriers are created by the insurance companies’ and
medical providers’ need to maximize profits. Many barriers can be overcome with legisla-
tion that improves eligibility and coverage. Still others can be overcome by targeting the
social and economic problems that plague America’s most vulnerable populations.

Critical Thinking

This chapter discusses several issues related to the barriers faced by America’s vulnerable populations
to accessing health care. Now that you have read this chapter, what do you think is the root of the prob-
lem? What short-term changes would you recommend to improve access? What long-term changes
would you recommend to improve access?

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CHAPTER 6

Additional Resources

4. In 2009, what percentage of women of childbearing age had no insurance cover-
age of any type?

a. 8.2%
b. 15.6%
c. 22.3%
d. 48.6%

5. How long is the waiting period for the Medicare SSDI program for disabled
people who are unable to work?

a. 2 years
b. 7 years
c. 12 years
d. 15 years

6. Many health care ___________ that once attempted to serve low-income areas
were put out of business by the increasing costs of treating victims of violence
who were unable to pay for their care.

a. substance abuse centers
b. criminal justice courts
c. domestic abuse victim services
d. trauma centers

Answer Key

1. b 2. c 3. b 4. c 5. a 6. d

Additional Resources

Visit the following websites to learn more about the topics covered in this chapter:

Information on the community-based and health care organization–based resources sup-
ported by the CARE Act

http://hab.hrsa.gov/

Healthy People, which discusses the goals of HHS for the next 10 years

http://www.healthypeople.gov/2020/default.aspx

The American Foundation for Suicide Prevention

http://www.afsp.org/

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http://hab.hrsa.gov/

http://www.healthypeople.gov/2020/default.aspx

http://www.afsp.org/

CHAPTER 6

Key Terms

childbearing age The age range of highest
fertility, which is 15 to 44.

compulsory Forced by legal or physical
means.

electronic health records Digital data-
bases that store patient health information,
making it accessible to all of a patient’s
approved providers.

epidemiology The study of how a disease
moves through populations.

equity Access and coverage being the
same for all people.

gynecological care Medical care specializ-
ing in the female reproductive system.

obstetricians Doctors who treat pregnant
women for pregnancy.

parity Access and coverage being the
same across health service types.

pathology The history of a disease.

physiological Having to do with the
physical body.

psychological Having to do with the
mind.

Web Exercise

Research at least five (5) credible websites regarding patient profiling as described in the
case study toward the end of the chapter. Write a five-page paper that does the following:

• defines and describes patient profiling
• describes two specific cases of patient profiling (one positive and one negative)
• identifies three positive issues and three negative issues of patient profiling
• identifies your personal stand on this issue and why you took that position

Remember: All papers must meet APA format. YouTube and Wikipedia are not considered
creditable sources. Citations must be included.

Key Terms

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