Access barriers related to communication problems may be particularly acute for the subset of Latino patients for whom Spanish is the primary language. However, language issues do not fully account for access barriers faced by Latinos. In the study of emergency department pain medication cited previously, even Latinos who spoke English as their primary language were much less likely than non-Latino whites to receive pain medication. ++ Because many of these hypotheses do not satisfactorily explain the observed racial and ethnic disparities in access to care, an important consideration is whether racism may also contribute to these patterns (King & Wheeler, 2016).

Neighborhoods that have high proportions of African-American or Latino residents have far fewer physicians practicing in these communities. African-American and Latino primary care physicians are more likely than white physicians to locate their practices in underserved communities (Komaromy et al., 1996; Marrast et al., 2014).

Because a far higher proportion of minorities than whites is uninsured, has Medicaid coverage, or is poor, access problems are amplified for these groups. In 2016, African American, Latino, Asian, and American Indian adults were twice as likely as whites to report difficulty obtaining a timely medical appointment for illness or injury. Analyzing a group of quality measures in 2014–16, African Americans received worse care than whites for 40% of these quality measures and Latinos and American Indians received worse care than whites for about one-third of the indicators. While some inequities in access and quality, such as adolescent immunization rates, have decreased over the past 15 years, others have widened, such as disparities in blood pressure control among African Americans relative to other groups (U.S. Agency for Healthcare Research and Quality, 2017). Overall, there has been a clear lack of progress on health equity over the past 25 years (Zimmerman and Anderson, 2019)

While women have reduced access to certain kinds of care, an equally serious problem may be instances of inappropriate care. Studies have found that between 16% and 70% of hysterectomies are inappropriate and that 38% of women undergoing hysterectomy for benign indications were not counseled on alternative, nonsurgical treatments (Corona et al., 2015).

Access problems for women begin with finding a physician who provides women’s health services. Forty-four percent of internists do not provide Pap smears (Cooper & Saraiya, 2014). Forty percent of reproductive age women have not been counseled on contraception with a care provider, 70% lack counseling on sexually transmitted infections, and 77% have not been counseled on domestic violence (Salganicoff et al., 2014). Contraceptive counseling is often provided with inadequate information and lack of patient-centered communication (Dehlendorf et al., 2014). Many women’s health providers are poorly informed about emergency contraception and almost one in five practitioners are reluctant to provide this education to sexually active adolescents. Women who are poor, foreign born, or who are not high school graduates are less likely to learn about emergency contraception (American College of Obstetricians and Gynecologists, 2015).

High cost-sharing is not only a feature of individual insurance plans. For people receiving health insurance from their employer, 81% must pay an annual deductible; the average 2018 deductible for a single employee working at a large firm was $1,355 and $2,132 for workers at small firms. These are costs over and above the employee’s share of the insurance premium. Since 2013 the average deductible for employed workers has increased by 53%. Most employed workers also pay an average of 19% of the cost of a hospital admission and a $25 copay for a primary care visit ($40 for a specialist visit). In addition, purchasing medications requires a copay (Fig. 3–4) (Claxton et al., 2018).

Government health insurance for the poor and the elderly added a new factor to the health care financing equation: the taxpayer (Fig. 2–4). With government-financed health plans, the taxpayer can interact with the health care consumer in two distinct ways: ++ The social insurance model, exemplified by Medicare, allows only those who have paid a certain amount of social security taxes to be eligible for Part A and only those who pay a monthly premium to receive benefits from Part B. As with private insurance, social insurance requires people to make a contribution in order to receive benefits. The contrasting model is the Medicaid public assistance model, in which those who contribute (taxpayers) may not be eligible for benefits (Bodenheimer & Grumbach,