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<div><div><ul><li><a href="/research/findings/nhqrdr/nhdr08/index.html">Contents</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Ackno.html">Acknowledgments</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Key.html">Key Themes and Highlights From the National Healthcare Disparities Report</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Chap1.html">Chapter 1. Introduction and Methods</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Chap2.html">Chapter 2. Quality of Health Care</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Chap3.html">Chapter 3. Access to Health Care</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Chap4.html">Chapter 4. Priority Populations</a></li><li><a href="/research/findings/nhqrdr/nhdr08/Core.html">Core Measures, Data Sources, and Availability for Select Groups</a></li><li>Appendixes</li><li><a href="https://www.ahrq.gov/research/findings/nhqrdr/nhqrdr11/datasources/index.html">Data Sources</a></li><li><a href="https://www.ahrq.gov/research/findings/nhqrdr/nhqrdr11/methods/index.html">Detailed Methods</a></li><li><a href="https://www.ahrq.gov/research/findings/nhqrdr/nhqrdr11/measurespec/index.html">Measure Specifications</a></li><li><a href="https://www.ahrq.gov/research/findings/nhqrdr/nhqrdr11/index.html">Data Tables</a></li></ul></div></div>
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<h1>Chapter 3. Access to Health Care (continued)</h1>
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<h2>National Healthcare Disparities Report, 2008</h2> <div id="basic-modal"><!-- start: Basic Modal -->
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<a id="care" name="care"></a> <h3>Health Care Utilization</h3><p>Measures of health care utilization complement patient reports of barriers to care and permit a fuller understanding of access to care. Barriers to care that are associated with differences in health care utilization may have a more significant impact on health care quality than other factors. Landmark reports on disparities have relied on measures of health care utilization,<sup><a href="#Ch3-Edn1">1</a>,</sup><sup><a href="#Ch3-Edn18">18</a></sup> and these data demonstrate some of the largest differences in care among diverse groups. More recent efforts to inform health care delivery continue to include measures of health care utilization.<sup><a href="#Ch3-Edn19">19</a></sup></p><p>Interpreting health care utilization data is more complex than analyzing data on patient perceptions of access to care. Along with access to care, health care utilization is strongly affected by health care need and patient preferences and values. In addition, greater use of services does not necessarily indicate better care. In fact, high use of some inpatient services may reflect impaired access to outpatient services.</p><p><a href="#Ch3-T1a">Tables 3.1a</a> and <a href="#Ch3-T1b">3.1b</a> summarize facilitators and barriers to care for various racial, ethnic, and socioeconomic groups. <a href="#Ch3-T2a">Tables 3.2a</a> and <a href="#Ch3-T2b">3.2b</a> summarize findings on all core measures related to health care utilization. Because of the many factors that affect health care utilization, the key to symbols used in <a href="#Ch3-T2a">Tables 3.2a</a> and <a href="#Ch3-T2b">3.2b</a> is different from that used for <a href="#Ch3-T1a">Tables 3.1a</a> and <a href="#Ch3-T1b">3.1b</a>. Rather than indicating better or worse access compared with the comparison group, symbols on the utilization tables simply identify the amount of care received by racial or ethnic minority and socioeconomic groups relative to their comparison groups.</p><p>In 2006, the Nation's 14 million health services workers<sup><a href="#Ch3-Edn20">20</a></sup> provided about 960 million office visits<sup><a href="#Ch3-Edn21">21</a></sup> and 673 million hospital outpatient visits<sup><a href="#Ch3-Edn22">22</a></sup> and treated 37 million hospitalized patients<sup><a href="#Ch3-Edn23">23</a></sup> and 1.4 million nursing home residents.<sup><a href="#Ch3-Edn23">23</a></sup> About 70% of the civilian noninstitutionalized population visit a medical provider's office or outpatient department, about 60% receive a prescription medicine, and about 40% visit a dental provider each year.<sup><a href="#Ch3-Edn24">24</a></sup></p><p>National health expenditures totaled over $2 trillion in fiscal year 2006, nearly double those of a decade earlier.<sup><a href="#Ch3-Edn25">25</a></sup> Health expenditures among the civilian noninstitutionalized population in America are extremely concentrated, with 5% of the population accounting for 55% of outlays.<sup><a href="#Ch3-Edn26">26</a></sup> In addition, a study using earlier data estimated that as much as $420 billion a year—almost one-third of all health care expenditures—are the result of low-quality care, including overuse, misuse, and waste.<sup><a href="#Ch3-Edn27">27</a></sup></p><p>Previous NHDRs reported that different racial, ethnic, and socioeconomic groups had different patterns of health care utilization. Asians and Hispanics tended to have lower use of most health care services, including routine care, emergency department visits, avoidable admissions, and mental health care. Blacks tended to have lower use of routine care, outpatient mental health care, and outpatient HIV care. Blacks had higher use of emergency departments and hospitals, including higher rates of avoidable admissions, inpatient mental health care, and inpatient HIV care. Individuals with lower SES tended to have lower use of routine care and outpatient mental health care and higher use of emergency departments, hospitals, and home heath care. In this section, findings related to dental care, emergency department visits, and mental health care and substance abuse treatment are highlighted.</p><h4>Dental Visits</h4><p>Regular dental visits promote prevention, early diagnosis,and optimal treatment of oral diseases and conditions. Failure to visit the dentist can result in delayed diagnosis, overall compromised health, and, occasionally, even death.<sup><a href="#Ch3-Edn28">28</a></sup></p><p class="caption"><strong><a id="Ch3fig10" name="Ch3fig10">Figure 3.10</a>. People who had a dental visit in the calendar year, by race (top left), ethnicity (top right), and income (bottom left), 2002-2005</strong></p><p><img alt="Trend line graphs show people who had a dental visit in the calendar year by race. Healthy People 2010 target: 56%. White, 2002, 46.4, 2003, 46.7, 2004, 45.9, 2005, 45.7 Black, 2002, 28.2, 2003, 29, 2004, 30.5, 2005, 30.5 Asian, 2002, 38.1, 2003, 38.1, 2004, 42.7, 2005, 41; NHOPI, 2002, 49.1, 2003, 44, 2004, 38.3, 2005, 41; AI/AN, 2002, 31.2, 2003, 35.8, 2004, 32, 2005, 32.6; > 1 Race, 2002, 34.3, 2003, 43.6, 2004, 41.8, 2005, 36.6" src="/research/findings/nhqrdr/nhdr08/images/fig3-10a.jpg" /> <img alt="Trend line graphs show people who had a dental visit in the calendar year by ethnicity. Healthy People 2010 target: 56%. Non-Hispanic White: 2002: 50.3%; 2003: 50.7%; 2004: 49.4%; 2005: 49.5%. Hispanic: 2002: 26.4%; 2003: 27.2%; 2004: 28.9%; 2005: 27.8%." src="/research/findings/nhqrdr/nhdr08/images/fig3-10b.jpg" /></p><p><img alt="Trend line graphs show people who had a dental visit in the calendar year by income. Healthy People 2010 target: 56%. Poor, 2002, 25.9, 2003, 26.2, 2004, 26.5, 2005, 27.1; Near Poor, 2002, 29.5, 2003, 30.1, 2004, 29.9, 2005, 29.7; Middle Income, 2002, 39.5, 2003, 42.4, 2004, 41.9, 2005, 41.5; High Income, 2002, 58.1, 2003, 58.3, 2004, 57.9, 2005, 56.9" src="/research/findings/nhqrdr/nhdr08/images/fig3-10c.jpg" /></p><p class="size2"><strong>Key</strong> AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.<br>
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<strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.<br>
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<strong>Reference population:</strong> Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population, all ages.</p><ul><li>There were no statistically significant changes in the percentage of people with a dental visit in the calendar year from 2002 to 2005 across racial, ethnic, or income categories (<a href="#Ch3fig10">Figure 3.10</a>).</li><li>From 2002 to 2005, the gap between Blacks and Whites in the percentage of people with a dental visit in the calendar year remained the same. In 2005, the percentage was significantly lower for Blacks than for Whites (30.5% compared with 45.7%).</li><li>During the same period, the gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the percentage was significantly lower for Hispanics than for non-Hispanic Whites (27.8% compared with 49.5%).</li><li>In 2005, the gap between poor people and high-income people remained the same. The percentage was significantly lower for poor (27.1%), near-poor (29.7%), and middle-income people (41.5%) than for high-income people (56.9%).</li><li>Only high-income people met the Healthy People 2010 target of 56% of people with a dental visit in the past year.</li></ul><p>To distinguish the effects of race, ethnicity, and SES status on health care utilization and to identify populations at greatest risk for barriers to health care utilization, this measure is stratified by income.</p><p class="caption"><strong><a id="Ch3fig11" name="Ch3fig11">Figure 3.1</a>1. People who had a dental visit in the calendar year, by race (left) and ethnicity (right), stratified by income, 2005</strong></p><p class="caption"><img alt="Trend line graphs show people who had a dental visit in the calendar year, by race, stratified by income, 2005. White: Poor: 29.1; Near Poor: 30.7; Middle Income: 43.0; High Income: 58.7. Black: Poor: 22.8; Near Poor: 25.2; Middle income: 32.3; High Income: 43.1. Asian: Poor: 24; Near Poor: 37; Middle Income: 39.1; High Income: 49." src="/research/findings/nhqrdr/nhdr08/images/fig3-11a.jpg" /> <img alt="Trend line graphs show people who had a dental visit in the calendar year, by ethnicity, stratified by income, 2005. Non-Hispanic White: Poor: 32.3; Near Poor: 34.9; Middle income: 45.8; High Income: 60.0. Hispanic: Poor: 22.9; Near Poor: 20.8; Middle income: 29.5; High Income: 43.1." src="/research/findings/nhqrdr/nhdr08/images/fig3-11b.jpg" /></p><p class="size2"><strong>Source:</strong> Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.<br>
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<strong>Reference population:</strong> Civilian noninstitutionalized population, all ages.<br>
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<strong>Note:</strong> Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.</p><ul><li>SES explains some, but not all, of the racial and ethnic differences in rates of dental visits (<a href="#Ch3fig11">Figure 3.11</a>).</li><li>In all income categories, Blacks were significantly less likely than Whites to have had a dental visit in the calendar year (poor, 22.8% for Blacks versus 29.1% for Whites; near poor, 25.2% for Blacks versus 30.7% for Whites; middle income, 32.3% for Blacks versus 43.0% for Whites; and high income, 43.1% for Blacks versus 58.7% for Whites).</li><li>Hispanics at every income level were significantly less likely than non-Hispanic Whites to have had a dental visit (poor, 22.9% of Hispanics versus 32.3% of non-Hispanic Whites; near poor, 20.8% of Hispanics versus 34.9% of non-Hispanic Whites; middle income, 29.5% of Hispanics versus 45.8% of non-Hispanic Whites; high income, 43.1% of Hispanics versus 60.0% of non-Hispanic Whites).</li></ul><h4>Emergency Department Visits</h4><p>Without good access to health care, people sometimes resort to using the emergency department (ED) when care is needed. A high rate of ED visits may suggest that a population lacks access to preventive and routine care and other avenues of treatment. Delaying care until care is urgent often results in poorer health outcomes and increased health care costs.</p><h4><a id="ch3fig12" name="ch3fig12">Figure 3.12</a>. Emergency department visits per 100 population in the calendar year, by race, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006</h4><p><img alt="Trend line graphs show emergency department visits per 100 population by race, 1997-2006. Race; 1997-1998 - Total, 36.4; White, 33.7; Black, 61; Asian, no data; 1999-2000, Total, 38.6; White, 36.1; Black, 61; Asian, no data; 2001-2002, Total, 38.6; White, 35.9; Black, 67; Asian, 18.9; 2003-2004, Total, 39.1; White, 36.2; Black, 69.1; Asian, no data; 2005-2006, Total, 40.1; White, 36.5; Black, 74.5; Asian, 17.7." src="/research/findings/nhqrdr/nhdr08/images/fig3-12.jpg" /></p><p class="size2"><strong>Source:</strong> Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006.<br>
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<strong>Denominator:</strong> Civilian noninstitutionalized population, all ages.<br>
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<strong>Note:</strong> Data did not meet criteria for statistical reliability for Asians (for data years 1997-1998, 1999-2000, and 2003-2004) and Native Hawaiians and Other Pacific Islanders.</p><ul><li>From 1997-1998 to 2005-2006, the rate of ED visits remained the same except for Blacks (<a href="#Ch3fig12">Figure 3.12</a>).</li><li>During this period, the gap between Blacks and Whites increased. In 2005-2006, the rate of ED visits was more than twice as high for Blacks as for Whites (74.5 per 100 population compared with 36.5 per 100 population).</li><li>In 2005-2006, the rate of ED visits was lower for Asians than for Whites (17.7 per 100 population compared with 36.5 per 100 population).</li><li>In 2005-2006, the rate of ED visits was higher for females than for males (42.5 per 100 population compared with 37.5 per 100 population; data not shown).</li></ul><h4>Potentially Avoidable Admissions</h4><p>Potentially avoidable admissions are hospitalizations that might have been averted by good outpatient care. They relate to conditions for which good outpatient care can prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. Although all admissions for these conditions cannot be avoided, rates in populations tend to vary with access to primary care.<sup><a href="#Ch3-Edn29">29</a></sup> For example, better access to care should reduce the percentage of appendicitis admissions in which rupture has already occurred.</p><p class="caption"><strong><a id="Ch3fig13" name="Ch3fig13">Figure 3.13</a>. Perforated appendixes per 1,000 admissions with appendicitis, by race/ethnicity (left) and area income (median income of ZIP Code of residence) (right), 2001-2005</strong></p><p class="caption"><img alt="Trend line graphs show perforated appendix per 1,000 adult admissions with appendicitis, by race/ethnicity , 2001-2005. Total, 2001, 314.3, 2002, 308.6, 2003, 299.7, 2004, 291.5, 2005, 287.2; White, 2001, 304.6, 2002, 303.1, 2003, 294.6, 2004, 287.8, 2005, 282.7; Black, 2001, 354.9, 2002, 346.9, 2003, 334.3, 2004, 308.7, 2005, 317.3; A P I, 2001, 316.3, 2002, 276.4, 2003, 270.1, 2004, 266.8, 2005, 270.1; Hispanic, 2001, 322.4, 2002, 306.1, 2003, 293.8, 2004, 291.8, 2005, 283.2" src="/research/findings/nhqrdr/nhdr08/images/fig3-13a.jpg" /> <img alt="Trend line graphs show perforated appendix per 1,000 adult admissions with appendicitis, by area income (median income of ZIP Code of residence), 2001-2005. $25,000, 2001, 332.8, 2002, 354.8, 2003, 332.2, 2004, 309.1, 2005, 308.8; $25,000-$34,999, 2001, 321.0, 2002, 331, 2003, 323, 2004, 298.9, 2005, 294.2; $35,000-$44,999, 2001, 314.2, 2002, 311, 2003, 309, 2004, 291.2, 2005, 284.3; $45,000+, 2001, 293.2, 2002, 297, 2003, 286, 2004, 270, 2005, 265.8" src="/research/findings/nhqrdr/nhdr08/images/fig3-13b.jpg" /></p><p class="size2"><strong>Key</strong> API = Asian or Pacific Islander.<br>
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<strong>Source:</strong> Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2001-2005.<br>
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<strong>Denominator:</strong> Patients hospitalized with appendicitis, age 18 and over.<br>
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<strong>Note:</strong> White, Black, and API are non-Hispanic groups. Numeric income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Income categories are based on the median household income of the ZIP Code of the patient's residence. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 64% of the U.S. resident population. Data for American Indians and Alaska Natives from NPIRS can be found in Chapter 4 but is not collected by this data source.</p><ul><li>From 2001 to 2005, the gap between Blacks and Whites in the rate of hospital admissions for perforated appendix decreased (<a href="#Ch3fig13">Figure 3.13</a>). In 2005, Blacks had a higher rate than Whites (317.3 per 1,000 compared with 282.7 per 1,000).</li><li>In 2005, APIs and Whites were not significantly different in the rate of hospital admissions for perforated appendix.</li><li>The gap between Hispanics and non-Hispanic Whites was eliminated. In 2005, there was no statistically significant difference between Hispanics and Whites (283.2 per 1,000 compared with 282.7 per 1,000).</li><li>From 2001 to 2005, the gap between people living in poor communities and those living in high-income communities in the rate of hospital admissions for perforated appendix increased. In 2005, people living in poor communities had a higher rate than those living in high-income communities (308.8 per 1,000 compared with 265.8 per 1,000).</li></ul><h4>Mental Health Care and Substance Abuse Treatment</h4><h5><strong>Mental Health Care</strong></h5><p>Although the prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for Whites,<sup><a href="#Ch3-Edn30">30</a></sup> minorities have less access to mental health care and are less likely to receive needed services.<sup><a href="#Ch3-Edn31">31</a></sup> These differences may reflect, in part, variation in preferences and cultural attitudes toward mental health.<sup><a href="#Ch3-Edn32">32</a></sup></p><p class="caption"><strong><a id="Ch3fig14" name="Ch3fig14">Figure 3.14</a>. Adults who received mental health treatment or counseling in the last 12 months, by race (top left), ethnicity (top right), and education (bottom left), 2003-2006</strong></p><p><img alt="Trend line graphs show percentage of adults who received mental health treatment or counseling in the last 12 months by race, 2003-2006. Total, 2003, 13.2, 2004, 12.8, 2005, 13, 2006, 12.9; White, 2003, 14.3, 2004, 13.8, 2005, 14, 2006, 14.0; Black, 2003, 8.6, 2004, 8.6, 2005, 8.9, 2006, 7.4; Asian, 2003, 4.8, 2004, 4.9, 2005, 4, 2006, 5.6; AI/AN, 2003, 10.2, 2004, 11.2, 2005, 12.7, 2006, 10.7; >1 Race, 2003, 17.2, 2004, 13.8, 2005, 13.3, 2006, 19.1" src="/research/findings/nhqrdr/nhdr08/images/fig3-14a.jpg" /> <img alt="Trend line graphs show percentage of adults who received mental health treatment or counseling in the last 12 months ethnicity, 2003-2006. Non-Hispanic White, 2003, 13.9, 2004, 14.9, 2005, 15.1, 2006, 15.2; Hispanic, 2003, 8, 2004, 7.4, 2005, 7.8.; 2006, 7.0" src="/research/findings/nhqrdr/nhdr08/images/fig3-14b.jpg" /> <img alt="Trend line graphs show percentage of adults who received mental health treatment or counseling in the last 12 months education, 2003-2006. High School, 2003, 10.5, 2004, 11.3, 2005, 10.9, 2006, 10.9; High School Grad, 2003, 12.5, 2004, 11.5, 2005, 11.6, 2006, 11.8; Some College, 2003, 14.6, 2004, 14.1, 2005, 14.4, 2006, 14.2" src="/research/findings/nhqrdr/nhdr08/images/fig3-14c.jpg" /></p><p class="size2"><strong>Key</strong> AI/AN = American Indian or Alaska Native.<br>
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<strong>Source:</strong> Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2006.<br>
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<strong>Reference population:</strong> U.S. population age 18 and over.<br>
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<strong>Note:</strong> Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders.</p><ul><li>From 2003 to 2006, the gap between Blacks and Whites remained the same (<a href="#Ch3fig14">Figure 3.14</a>). In 2006, Blacks were significantly less likely than Whites to receive mental health treatment or counseling (7.4% compared with 14.0%).</li><li>In 2006, there was no statistically significant difference between AI/ANs and Whites.</li><li>The gap between Asians and Whites in the percentage of people who received mental health treatment or counseling remained the same. In 2006, the percentage of Asians was less than half that of Whites (5.6% compared with 14.0%).</li><li>The gap between Hispanics and non-Hispanic Whites remained the same. In 2006, the percentage of Hispanics was less than half that of non-Hispanic Whites (7.0% compared with 15.2%).</li><li>The gap in mental health service use between people with less than a high school education and people with some college education remained the same. In 2006, the percentage was lower for people with less than a high school education (10.9%) and for people with a high school education (11.8%) than for people with some college education (14.2%).</li><li>In 2006, there were no statistically significant differences between people of different income levels in the receipt of mental health treatment or counseling (data not shown).</li></ul><h5><strong>Substance Abuse Treatment</strong></h5><p>In 2006, about 17 million Americans age 12 and over acknowledged being heavy alcohol drinkers, and about 57 million acknowledged having had a recent binge drinking episode.<sup><a href="#Ch3-Edn32">32</a></sup> About 20.4 million people age 12 and over were illicit drug users, and about 72.9 million reported recent use of a tobacco product.<sup><a href="#Ch3-Edn33">33</a></sup> In 2001, an estimated $18 billion was devoted to treatment of substance use disorders. This amount constituted 1.3% of all health care spending.<sup><a href="#Ch3-Edn33">33</a></sup></p><p>Racial, ethnic, and socioeconomic differences in substance abuse treatment<sup><a href="#Ch3-Edn32">32</a></sup> may, in part, reflect variation in preferences and cultural attitudes toward mental health and substance abuse.</p><p class="caption"><strong><a id="Ch3fig15" name="Ch3fig15">Figure 3.15</a>. People age 12 and over who received any treatment for illicit drug or alcohol abuse in the last 12 months, by race (top left), ethnicity (top right), and education (bottom left), 2003-2006</strong></p><p><img alt="Trend line graphs show percentage of people age 12 and over who received any illicit drug or alcohol abuse treatment in the last 12 months, by race, 2003-2006. Total, 2003, 1.4, 2004, 1.6, 2005, 1.6, 2006, 1.6; White, 2003, 1.4, 2004, 1.4, 2005, 1.5, 2006, 1.6; Black, 2003, 1.7, 2004, 2.5, 2005, 2.5, 2006, 2.3; Asian, 2003, 0.4, 2004, 0.4, 2005, 0.4, 2006, 0.4; NHOPI, 2003, 2, 2004, No data, 2005, 1, 2006, 1.6; AI/AN, 2003, 4.5, 2004, 3.2, 2005, 3, 2006, 3.8" src="/research/findings/nhqrdr/nhdr08/images/fig3-15a.jpg" /> <img alt="Trend line graphs show percentage of people age 12 and over who received any illicit drug or alcohol abuse treatment in the last 12 months, ethnicity, 2003-2006. Non-Hispanic White, 2003, 1.3, 2004, 1.4, 2005, 1.5, 2006, 1.5; Hispanic, 2003, 1.8, 2004, 1.6, 2005, 2, 2006, 2.4" src="/research/findings/nhqrdr/nhdr08/images/fig3-15b.jpg" /> <img alt="Trend line graphs show percentage of people age 12 and over who received any illicit drug or alcohol abuse treatment in the last 12 months, by education, 2003-2006. High School, 2003, 2.3, 2004, 2.8, 2005, 2.7, 2006, 3.2; High School Grad, 2003, 1.6, 2004, 1.8, 2005, 1.8, 2006, 1.8; Some College, 2003, 1, 2004, 1, 2005, 1.2, 2006, 1.1" src="/research/findings/nhqrdr/nhdr08/images/fig3-15c.jpg" /></p><p class="size2"><strong>Key</strong> AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.<br>
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<strong>Source:</strong> Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2006.<br>
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<strong>Reference population:</strong> U.S. population age 12 and over.<br>
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<strong>Note:</strong> The figure reflects both prevalence and treatment; variations in prevalence likely have an effect on racial and ethnic differences in treatment.</p><ul><li>From 2003 to 2006, the gap between AI/ANs and Whites in the percentage of people age 12 and over who received any treatment for illicit drug or alcohol abuse remained the same (<a href="#Ch3fig15">Figure 3.15</a>). In 2005, the percentage was more than two times higher for AI/ANs than for Whites (3.8% compared with 1.6%).</li><li>During this period, the gap between Asians and Whites in the percentage of people age 12 and over who received drug or alcohol abuse treatment remained the same. In 2006, the percentage of people age 12 and over who received any illicit drug or alcohol abuse treatment was lower for Asians than for Whites (0.4% compared with 1.6%).</li><li>During this period, there were no significant differences between Hispanics and non-Hispanic Whites.</li><li>The gap between people with less than a high school education and people with some college education increased. In 2006, the percentage was more than two times higher for people with less than a high school education than for people with some college education (3.2% compared with 1.1%).</li></ul><a id="tables" name="tables"></a> <h3>Summary Tables</h3><p><strong><a id="Ch3-T1a" name="Ch3-T1a">Table 3.1a.</a> Racial and Ethnic Differences in Facilitators and Barriers to Health Care</strong></p><table border="1" cellpadding="2" cellspacing="0" width="90%"><thead><tr><th align="left" height="42" rowspan="2" scope="col">Core Report Measure</th><th align="center" colspan="5" scope="col">Racial Difference<a href="#Ch3-T1a-1"><sup>i</sup></a></th><th align="center" scope="col">Ethnic<br /> Difference<a href="#Ch3-T1a-2"><sup>ii</sup></a></th></tr><tr><th align="left" scope="col">Black</th><th align="center" scope="col">Asian</th><th align="center" scope="col">NHOPI</th><th align="center" scope="col">AI/AN</th><th align="center" scope="col">>1 Race</th><th align="center" scope="col">Hispanic</th></tr></thead><tbody><tr><td align="left" colspan="7" scope="row"><strong>Health Insurance Coverage</strong></td></tr><tr><td scope="row">People under age 65 with health insurance<a href="#Ch3-T1a-3"><sup>iii</sup></a></td><td align="center">=</td><td align="center">=</td><td align="center">=</td><td align="center">↓</td><td align="center">=</td><td align="center">↓</td></tr><tr><td scope="row">People under age 65 who were uninsured all year<a href="#Ch3-T1a-4"><sup>iv</sup></a></td><td align="center">↓</td><td align="center">=</td><td align="center">=</td><td align="center">↓</td><td align="center">=</td><td align="center">↓</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Usual Source of Care</strong></td></tr><tr><td scope="row">People with a specific source of ongoing care<a href="#Ch3-T1a-3"><sup>iii</sup></a></td><td align="center">=</td><td align="center">=</td><td> </td><td> </td><td align="center">=</td><td align="center">↓</td></tr><tr><td scope="row">People with a usual primary care provider<a href="#Ch3-T1a-4"><sup>iv</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">=</td><td align="center">=</td><td align="center">↓</td></tr><tr><td scope="row">People without a usual source of care who indicated a financial or insurance reason for not having a source of care<a href="#Ch3-T1a-4"><sup>iv</sup></a></td><td align="center">↑</td><td align="center">=</td><td align="center"> </td><td> </td><td align="center">=</td><td align="center">↓</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Patient Perceptions of Need</strong></td></tr><tr><td scope="row">People who were unable to get or delayed in getting needed care<a href="#Ch3-T1a-4"><sup>iv</sup></a></td><td align="center">↓</td><td> </td><td> </td><td> </td><td align="center">↓</td><td align="center">↓</td></tr><tr><td scope="row">People unable to get or delayed in getting needed care due to financial or insurance reasons<a href="#Ch3-T1a-4"><sup>iv</sup></a></td><td align="center">=</td><td align="center">=</td><td> </td><td> </td><td align="center">↓</td><td align="center">↓</td></tr></tbody></table><p class="size2"><a id="Ch3-T1a-1" name="Ch3-T1a-1"><sup>i</sup></a> Compared with Whites.<br /> <a id="Ch3-T1a-2" name="Ch3-T1a-2"><sup>ii</sup></a> Compared with non-Hispanic Whites.<br /> <a id="Ch3-T1a-3" name="Ch3-T1a-3"><sup>iii</sup></a> Source: National Health Interview Survey, 2006.<br /> <a id="Ch3-T1a-4" name="Ch3-T1a-4"><sup>iv</sup></a> Source: Medical Expenditure Panel Survey, 2005.</p><p class="size2"><strong>Key</strong> NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.</p><table border="1" cellpadding="4" cellspacing="0" width="90%"><tbody><tr><td><strong>Key to Symbols Used in Access to Health Care Tables:</strong> <br /> = Group and comparison group have about same access to health care.<br /> ↑ Group has better access to health care than the comparison group.<br /> ↓ Group has worse access to health care than the comparison group.<br /> Blank cell: Reliable estimate for group could not be made.</td></tr></tbody></table><p><strong><a id="Ch3-T1b" name="Ch3-T1b">Table 3.1b.</a> Socioeconomic Differences in Facilitators and Barriers to Health Care</strong></p><table border="1" cellpadding="2" cellspacing="0" width="90%"><thead><tr><th align="left" height="42" rowspan="2" scope="col">Core Report Measure</th><th align="center" colspan="3" scope="col">Income Difference<a href="#Ch3-T1b-1"><sup>i</sup></a></th><th align="center" colspan="2" scope="col">Educational Difference<a href="#Ch3-T1b-2"><sup>ii</sup></a></th><th align="center" scope="col">Ethnic Difference<a href="#Ch3-T1b-3"><sup>iii</sup></a></th></tr><tr><th align="center" scope="col"><100%</th><th align="center" scope="col">100 199%</th><th align="center" scope="col">200 399%</th><th align="center" scope="col"><HS</th><th align="center" scope="col">HS Grad</th><th align="center" scope="col">Uninsured</th></tr></thead><tbody><tr><td align="left" colspan="7" scope="row"><strong>Health Insurance Coverage</strong></td></tr><tr><td scope="row">People under age 65 with health<br /> insurance<a href="#Ch3-T1b-4"><sup>iv</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">↓</td><td align="center"> </td></tr><tr><td scope="row">People under age 65 who were<br /> uninsured all year<a href="#Ch3-T1b-5"><sup>v</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">↓</td><td align="center"> </td></tr><tr><td align="left" colspan="7" scope="row"><strong>Usual Source of Care</strong></td></tr><tr><td scope="row">People with a specific source of<br /> ongoing care<a href="#Ch3-T1b-4"><sup>iv</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">↓</td><td align="center">↓</td></tr><tr><td scope="row">People with a usual primary care<br /> provider<a href="#Ch3-T1b-5"><sup>v</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">=</td><td align="center">↓</td></tr><tr><td scope="row">People without a usual source of care<br /> who indicated a financial or insurance<br /> reason for not having a source of care<a href="#Ch3-T1b-4"><sup>iv</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">=</td><td align="center">↓</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Patient Perceptions of Need</strong></td></tr><tr><td scope="row">People who were unable to get or<br /> delayed in getting needed care<a href="#Ch3-T1b-5"><sup>v</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">↓</td><td align="center">↓</td></tr><tr><td scope="row">People unable to get or<br /> delayed in getting needed care due to<br /> financial or insurance reasons<a href="#Ch3-T1b-5"><sup>v</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">=</td><td align="center">↓</td></tr></tbody></table><p class="size2"><a id="Ch3-T1b-1" name="Ch3-T1b-1"><sup>i</sup></a> Compared with persons with family incomes 400% of Federal poverty thresholds or above.<br /> <a id="Ch3-T1b-2" name="Ch3-T1b-2"><sup>ii</sup></a> Compared with persons with any college education.<br /> <a id="Ch3-T1b-3" name="Ch3-T1b-3"><sup>iii</sup></a> Compared with persons under 65 with any private health insurance.<br /><a id="Ch3-T1b-4" name="Ch3-T1b-4"><sup>iv</sup></a> Source: National Health Interview Survey, 2006.<br /> <a id="Ch3-T1b-5" name="Ch3-T1b-5"><sup>v</sup></a> Source: Medical Expenditure Panel Survey, 2005.</p><p class="size2"><strong>Key</strong> HS=High school.</p><table border="1" cellpadding="4" cellspacing="0" width="90%"><tbody><tr><td><strong>Key to Symbols Used in Access to Health Care Tables:</strong> <br /> = Group and comparison group have about same access to health care.<br /> ↑ Group has better access to health care than the comparison group.<br /> ↓ Group has worse access to health care than the comparison group.<br /> Blank cell: Reliable estimate for group could not be made.</td></tr></tbody></table><p><strong><a id="Ch3-T2a" name="Ch3-T2a">Table 3.2a.</a> Racial and Ethnic Differences in Health Care Utilization</strong></p><table border="1" cellpadding="2" cellspacing="0" width="90%"><thead><tr><th align="left" height="42" rowspan="2" scope="col">Core Report Measure</th><th colspan="5" scope="col" valign="middle">Racial Difference<a href="#Ch3-T2a-1"><sup>i</sup></a><a href="#Ch3-T2a-2"></a></th><th scope="col" valign="middle">Ethnic<br /> Difference<a href="#Ch3-T2a-2"><sup>ii</sup></a></th></tr><tr><th scope="col" valign="middle">Black</th><th scope="col" valign="middle">Asian</th><th scope="col" valign="middle">NHOPI</th><th scope="col" valign="middle">AI/AN</th><th scope="col" valign="middle"><1 Race</th><th scope="col" valign="middle">Hispanic</th></tr></thead><tbody><tr><td align="left" colspan="7" scope="row"><strong>General Medical Care</strong> </td></tr><tr><td scope="row">People who had a dental visit in the calendar year <a href="#Ch3-T2a-3"><sup>iii</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">=</td><td align="center">↓</td><td align="center">↓</td><td align="center">↓</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Avoidable Admissions</strong> </td></tr><tr><td scope="row">Perforated appendixes per 1,000 admissions with appendicitis<a href="#Ch3-T2a-4"><sup>iv</sup></a> </td><td align="center">=</td><td align="center" colspan="2">=</td><td align="center"> </td><td align="center"> </td><td align="center">=</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Mental Health Care and Substance Abuse Treatment</strong> </td></tr><tr><td scope="row">Adults who received mental health treatment or counseling in the last 12 months<a href="#Ch3-T2a-5"><sup>v</sup></a></td><td align="center">=</td><td align="center">↓</td><td align="center">↓</td><td align="center">=</td><td align="center">=</td><td align="center">=</td></tr><tr><td scope="row">People age 12 and older who received any treatment for illicit drug or alcohol abuse in the last 12 months<a href="#Ch3-T2a-5"><sup>v</sup></a></td><td align="center">↑</td><td align="center">↓</td><td align="center"> </td><td align="center">=</td><td align="center">=</td><td align="center">=</td></tr></tbody></table><p class="size2"><a id="Ch3-T2a-1" name="Ch3-T2a-1"><sup>i</sup></a> Compared with Whites.<br /> <a id="Ch3-T2a-2" name="Ch3-T2a-2"><sup>ii</sup></a> Compared with non-Hispanic Whites.<br /> <a id="Ch3-T2a-3" name="Ch3-T2a-3"><sup>iii</sup></a> <strong>Source:</strong> Medical Expenditure Panel Survey, 2005.<br /> <a id="Ch3-T2a-4" name="Ch3-T2a-4"><sup>iv</sup></a> <strong>Source:</strong> HCUP SID disparities analysis file, 2005. This source categorizes race/ethnicity very differently from other sources. Race/ethnicity information is categorized as a single item: Non-Hispanic White, Non-Hispanic Black, Hispanic, Asian or Pacific Islander. These contrasts compare each group with non-Hispanic Whites.<br /> <a id="Ch3-T2a-5" name="Ch3-T2a-5"><sup>v</sup></a> <strong>Source:</strong> Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2006.</p><p class="size2"><strong>Key</strong> NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.</p><table border="1" cellpadding="4" cellspacing="0" width="90%"><tbody><tr><td><strong>Key to Symbols Used in Health Care Utilization Tables:</strong> <br /> = Group and comparison group receive about the same amount of health care.<br /> ↑ Group receives more health care than the comparison group.<br /> ↓ Group receives less health care than the comparison group.<br /> Blank cell: Reliable estimate for group could not be made.</td></tr></tbody></table><p><strong><a id="Ch3-T2b" name="Ch3-T2b">Table 3.2b.</a> Socioeconomic Differences in Health Care Utilization</strong></p><table border="1" cellpadding="2" cellspacing="0" width="90%"><thead><tr><th align="left" height="42" rowspan="2" scope="col" width="39%">Core Report Measure</th><th colspan="3" scope="col" valign="middle">Income<br /> Difference<a href="#Ch3-T2b-1"><sup>i</sup></a></th><th colspan="2" scope="col" valign="middle">Educational<br /> Difference<a href="#Ch3-T2b-2"><sup>ii</sup></a></th><th scope="col" valign="middle" width="15%">Insurance<br /> Difference<a href="#Ch3-T2b-3"><sup>iii</sup></a></th></tr><tr><th align="center"><100%</th><th align="center">100 199%</th><th align="center">200 399%</th><th align="center"><HS</th><th align="center">HS Grad</th><th align="center">Uninsured</th></tr></thead><tbody><tr><td align="left" colspan="7" scope="row"><strong>General Medical Care</strong> </td></tr><tr><td scope="row">People who had a dental visit in the calendar year <a href="#Ch3-T2b-4"><sup>iv</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center">↓</td><td align="center">↓</td><td align="center">↓</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Avoidable Admissions</strong> </td></tr><tr><td scope="row">Perforated appendixes per 1,000 admissions with appendicitis</td><td align="center">↓</td><td align="center">↓</td><td align="center">↑</td><td align="center"> </td><td align="center"> </td><td align="center">↓</td></tr><tr><td align="left" colspan="7" scope="row"><strong>Mental Health Care and Substance Abuse Treatment</strong> </td></tr><tr><td scope="row">Adults who received mental health treatment or counseling in the last 12 months <a href="#Ch3-T2b-5"><sup>v</sup></a></td><td align="center">=</td><td align="center">=</td><td align="center">=</td><td align="center">=</td><td align="center">=</td><td align="center"> </td></tr><tr><td scope="row">People age 12 and older who received any treatment for illicit drug or alcohol abuse in the last 12 months<a href="#Ch3-T2b-5"><sup>v</sup></a></td><td align="center">↓</td><td align="center">↓</td><td align="center">=</td><td align="center">↑</td><td align="center">=</td><td align="center"> </td></tr></tbody></table><p class="size2"><a id="Ch3-T2b-1" name="Ch3-T2b-1"><sup>i</sup></a> Compared with persons with family incomes 400% of Federal poverty threshold or above.<br /> <a id="Ch3-T2b-2" name="Ch3-T2b-2"><sup>ii</sup></a> Compared with persons with any college education.<br /> <a id="Ch3-T2b-3" name="Ch3-T2b-3"><sup>iii</sup></a> Compared with persons under 65 with any private health insurance.<br /> <a id="Ch3-T2b-4" name="Ch3-T2b-4"><sup>iv</sup></a> <strong>Source:</strong> Medical Expenditure Panel Survey, 2005.<br /> <a id="Ch3-T2b-5" name="Ch3-T2b-5"><sup>v</sup></a> <strong>Source:</strong> Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2006. Insurance disparities were not analyzed.</p><p class="size2"><strong>Key</strong> HS = high school.</p><table border="1" cellpadding="4" cellspacing="0" width="90%"><tbody><tr><td><strong>Key to Symbols Used in Health Care Utilization Tables:</strong><br /> = Group and comparison group receive about same amount of health care.<br /> ↑ Group receives more health care than the comparison group.<br /> ↓ Group receives less health care than the comparison group.<br /> Blank cell: Reliable estimate for group could not be made.</td></tr></tbody></table><p class="size2" /><a id="ref" name="ref"></a>
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<h3>References</h3><p><a id="Ch3-Edn1" name="Ch3-Edn1">1.</a> Millman M, ed. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993.</p><p><a id="Ch3-Edn2" name="Ch3-Edn2">2.</a> Bierman A, Magari ES, Jette AM, et al. Assessing access as a first step toward improving the quality of care for very old adults. <em>J Ambul Care Manage</em> 1998 Jul;121(3):17-26.</p><p><a id="Ch3-Edn3" name="Ch3-Edn3">3.</a> Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. <em>JAMA</em> 2007;297(10):1073-84.</p><p><a id="Ch3-Edn4" name="Ch3-Edn4">4.</a> Insuring America's health: principles and recommendations. <em>Acad Emerg Med</em> 2004;11(4):418-22.</p><p><a id="Ch3-Edn5" name="Ch3-Edn5">5.</a> Self-assessed health status and selected behavioral risk factors among persons with and without healthcare coverage—United States, 1994-1995. <em>MMWR Morb Mortal Wkly Rep</em> 1998 Mar 13;47(9):176-80. Available at: <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/00051507.htm">http://www.cdc.gov/mmwr/preview/mmwrhtml/00051507.htm</a>.</p><p><a id="Ch3-Edn6" name="Ch3-Edn6">6</a> Jacoby MB, Sullivan TA, Warren E. Medical problems and bankruptcy filings. <em>Norton Bankruptcy Law Adviser</em> 2000 May;5:1-12.</p><p><a id="Ch3-Edn7" name="Ch3-Edn7">7.</a> Hadley J. Sicker and poorer: the consequences of being uninsured. Paper prepared for the Kaiser Commission on Medicaid and the Uninsured. Washington, DC: The Urban Institute; May 2002 (updated February 2003).</p><p><a id="Ch3-Edn8" name="Ch3-Edn8">8.</a> DeNavas-Walt C, Proctor BD, Lee CH, U.S. Census Bureau. Income, poverty, and health insurance coverage in the United States: 2005. Current Population Reports, P60-231. Washington, DC: Government Printing Office; 2006. Available at: <a href="http://www.census.gov/prod/2006pubs/p60-231.pdf">http://www.census.gov/prod/2006pubs/p60-231.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed June 7, 2006.</p><p><a id="Ch3-Edn9" name="Ch3-Edn9">9.</a> Starfield B, Shi L. The medical home, access to care, and insurance. <em>Pediatrics</em> 2004;113(5 Suppl):1493-8.</p><p><a id="Ch3-Edn10" name="Ch3-Edn10">10.</a> De Maeseneer JM, De Prins L, Gosset C, et al. Provider continuity in family medicine: does it make a difference for total health care costs? <em>Ann Fam Med</em> 2003;1:144-8.</p><p><a id="Ch3-Edn11" name="Ch3-Edn11">11.</a> U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and improving health and objectives for improving health. 2 vols. Washington, DC: Government Printing Office; November 2000. p.45. Available at: <a href="http://www.healthypeople.gov/">http://www.healthypeople.gov</a>.</p><p><a id="Ch3-Edn12" name="Ch3-Edn12">12.</a> Phillips RL, Proser M, Green LA, et al. The importance of having health insurance and a usual source of care. One-Pager Number 29. Washington, DC: The Robert Graham Center: Policy Studies in Family Practice and Primary Care; September 2004. Available at: http://www.graham-center.org/online/graham/home/publications/onepagers/2004/op29-importance-insurance.html. Accessed October 30, 2007.</p><p><a id="Ch3-Edn13" name="Ch3-Edn13">13.</a> Mainous 3rd AG, Baker R, Love MM, et al. Continuity of care and trust in one's physician: evidence from primary care in the United States and the United Kingdom. <em>Fam Med</em> 2001 Jan;33(1):22-7.</p><p><a id="Ch3-Edn14" name="Ch3-Edn14">14.</a> Starfield B. Primary care: balancing health needs, services and technology. New York: Oxford University Press; 1998.</p><p><a id="Ch3-Edn15" name="Ch3-Edn15">15.</a> Forrest C, Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures. <em>J Fam Pract</em> 1996 Jul;43(1):40-8.</p><p><a id="Ch3-Edn16" name="Ch3-Edn16">16.</a> Parchman ML, Burge SK. Residency Research Network of South Texas investigators. Continuity and quality of care in type 2 diabetes: a Residency Research Network of South Texas study. <em>J Fam Pract</em> 2002 Jul;51(7):619-24.</p><p><a id="Ch3-Edn17" name="Ch3-Edn17">17.</a> Inkelas M, Schuster MA, Olson LM, et al. Continuity of primary care clinician in early childhood. <em>Pediatrics</em> 2004 June;113(6 Suppl):1917-25.</p><p><a id="Ch3-Edn18" name="Ch3-Edn18">18.</a> U.S. Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: DHHS; 1985.</p><p><a id="Ch3-Edn19" name="Ch3-Edn19">19.</a> Swift EK, ed. Institute of Medicine, Committee on Guidance for Designing a National Healthcare Disparities Report. Guidance for the National Healthcare Disparities Report. Washington, DC: National Academies Press; 2002. p. 20.</p><p><a id="Ch3-Edn20" name="Ch3-Edn20">20.</a> Table 105: Persons employed in health service sites, by sex: United States, selected years 2000-2006. In: National Center for Health Statistics. Health, United States, 2007. With chartbook on trends in the health of Americans. Hyattsville, MD: Centers for Disease Control and Prevention; 2007. Available at: <a href="http://www.cdc.gov/nchs/data/hus/hus07.pdf">http://www.cdc.gov/nchs/data/hus/hus07.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed September 18, 2008.</p><p><a id="Ch3-Edn21" name="Ch3-Edn21">21.</a> Table 92: Visits to physician offices and hospital outpatient and emergency departments, by selected characteristics: United States, selected years 1995-2005.<br /> In: National Center for Health Statistics. Health, United States, 2007. With chartbook on trends in the health of Americans. Hyattsville, MD: Centers for Disease Control and Prevention; 2007. Available at: <a href="http://www.cdc.gov/nchs/data/hus/hus07.pdf">http://www.cdc.gov/nchs/data/hus/hus07.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed September 18, 2008.</p><p><a id="Ch3-Edn22" name="Ch3-Edn22">22.</a> Table 103: Hospital admissions, average length of stay, outpatient visits, and outpatient surgery by type of ownership and size of hospital: United States, selected years 1975-2005. In: National Center for Health Statistics. Health, United States, 2007. With chartbook on trends in the health of Americans. Hyattsville, MD: Centers for Disease Control and Prevention; 2007. Available at: <a href="http://www.cdc.gov/nchs/data/hus/hus07.pdf">http://www.cdc.gov/nchs/data/hus/hus07.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed September 18, 2008.</p><p><a id="Ch3-Edn23" name="Ch3-Edn23">23.</a> Table 104: Nursing homes, beds, occupancy, and residents, by geographic division and State: selected years 1995-2005. In: National Center for Health Statistics. Health, United States, 2007. With chartbook on trends in the health of Americans. Hyattsville, MD: Centers for Disease Control and Prevention; 2007. Available at: <a href="http://www.cdc.gov/nchs/data/hus/hus07.pdf">http://www.cdc.gov/nchs/data/hus/hus07.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed September 18, 2008.</p><p><a id="Ch3-Edn24" name="Ch3-Edn24">24.</a> Krauss N, Machlin S, Kass BL. Use of health care services, 1996. Rockville, MD: Agency for Health Care Policy and Research, 1999. MEPS Findings No. 7, AHCPR Publication No. 99-0018.</p><p><a id="Ch3-Edn25" name="Ch3-Edn25">25.</a> Office of the Actuary. National health expenditure data/historical. Baltimore: Centers for Medicare & Medicaid Services. Available at: <a href="http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf">http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed September 18, 2008.</p><p><a id="Ch3-Edn26" name="Ch3-Edn26">26.</a> Berk ML, Monheit AC. The concentration of health care expenditures, revisited. <em>Health Aff</em> 2001 Mar/Apr; 20(2):9-18.</p><p><a id="Ch3-Edn27" name="Ch3-Edn27">27.</a> Reducing the costs of poor-quality health care through responsible purchasing leadership. Chicago: Midwest Business Group on Health; 2003. Available at: http://www.mbgh.org/templates/UserFiles/Files/COPQ/copq%202nd%20printing.pdf. Accessed October 30, 2007.</p><p><a id="Ch3-Edn28" name="Ch3-Edn28">28.</a> Fryer GE, Dovey SM, Green LA. The importance of having a usual source of health care. One-Pager Number 2. Washington, DC: The Robert Graham Center: Policy Studies in Family Practice and Primary Care; January 2000. Available at: http://www.graham-center.org/online/graham/home/publications/onepagers/2000/op2-usual-source.html. Accessed October 30, 2007.</p><p><a id="Ch3-Edn29" name="Ch3-Edn29">29.</a> Oster A, Bindman AB. Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations. <em>Med Care</em> 2003 Feb;41(2):198-207.</p><p><a id="Ch3-Edn30" name="Ch3-Edn30">30.</a> Office of Applied Studies. The NSDUH report: co-occurring major depressive episode (MDE) and alcohol use disorder among adults. Rockville, MD: Substance Abuse and Mental Health Services Administration; February 2007. Available at: <a href="http://www.oas.samhsa.gov/2k7/alcDual/alcDual.cfm">http://www.oas.samhsa.gov/2k7/alcDual/alcDual.cfm</a>. Accessed May 30, 2007.</p><p><a id="Ch3-Edn31" name="Ch3-Edn31">31.</a> Center for Mental Health Services. Mental health: culture, race and ethnicity—a supplement to Mental Health: Report of the Surgeon General. Executive Summary. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2001. Available at: <a href="http://mentalhealth.samhsa.gov/cre/default.asp">http://mentalhealth.samhsa.gov/cre/default.asp</a>.</p><p><a id="Ch3-Edn32" name="Ch3-Edn32">32.</a> Office of Applied Studies. Results from the 2006 National Survey on Drug Use and Health: national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007. NSDUH Series H-32, DHHS Publication No. SMA 07-4293. Available at: <a href="http://www.oas.samhsa.gov/NSDUH/2K6NSDUH/2K6results.cfm">http://www.oas.samhsa.gov/NSDUH/2K6NSDUH/2K6results.cfm</a>.</p><p><a id="Ch3-Edn33" name="Ch3-Edn33">33.</a> Mark T, Coffey RM, McKusick D, et al. National expenditures for mental health services and substance abuse treatment, 1991-2001. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. DHHS Publication No. SMA 05-3999. Available at: <a href="http://www.samhsa.gov/spendingestimates/SEPGenRpt013105v2BLX.pdf">http://www.samhsa.gov/spendingestimates/SEPGenRpt013105v2BLX.pdf</a> [<a href="http://www.hhs.gov/web/tools/plugins.html">Plugin Software Help</a>]. Accessed on July 31, 2007.<br />
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