Did Disparities in Access Worsen During the Pandemic? (CHCF Brief)

The following content is cross-posted from California Health Care Foundation 
Author: Lacey Hartman, SHADAC

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Previous research has shown that Medi-Cal enrollees fare worse in accessing health care than Californians with employer coverage. A key question is whether and how access to care shifted during the pandemic for the two groups. For example, did existing differences in access worsen or improve? Have new access challenges emerged for those with Medi-Cal, compared to those with employer coverage?

To answer these questions, authors of a new CHCF brief compared data from the 2017–18 and 2020–21 California Health Interview Survey (CHIS). Separate analyses were done for adults and children.

Key findings include:

• Data show that the pandemic did not widen differences in access to care for people with Medi-Cal coverage compared to those with employer coverage. This held true for both adults and children.
• Rather, among adults, there was some narrowing of differences on select measures. However, this is not a positive development, as it appears to have been caused by worsening access to care for adults with employer-sponsored insurance coverage during the pandemic rather than improvements for adults with Medi-Cal.

Authors note that a key issue going forward is how the end of the federal Medicaid continuous coverage requirement will impact access to care among Californians.

Planalp, Colin
Research Fellow

p 612-624-4850
e cplanalp@umn.edu

Minnesota’s COVID-19 vaccine campaign left vulnerable groups with lagging rates

Health inequities are nothing new in Minnesota, but the pandemic placed them in a new light. Numerous studies have reported disparities in how COVID-19 affects many vulnerable groups, often placing them at higher risk of infection, hospitalization, and death. And the inequitable effects of the disease itself are not the only cause for alarm. Once COVID-19 vaccines received authorization, disparities in vaccination rates also became a concern, especially as surveys indicated widespread hesitancy and lagging uptake.

Partnering with the Minnesota Electronic Health Record Consortium, SHADAC delved deep into an analysis of COVID-19 vaccination rates in Minnesota. Unlike many other studies, we were able to examine not only how COVID-19 vaccination rates differed across different demographic groups, but also how those disparities developed over time. This type of analysis was possible because of the Consortium’s unique dataset, which matches data from large health care providers’ electronic health records—including detailed demographics with immunization records from the Minnesota Department of Health, ultimately covering almost all people who received a COVID-19 vaccine in the state.

Understanding the dynamics of vaccination disparities over time was a crucial element of our study. While we present data on COVID-19 vaccination rates for different demographic subpopulations at the end of 2022, we also examined the time it took to reach 50 percent of people in different demographic groups with COVID-19 vaccinations. That measure of time to vaccination is important because, in a public health crisis during which hundreds or even thousands of people were dying each day at its peak in the U.S. alone, the speed with which people were vaccinated was critical to saving lives.

Our approach also allowed us to glean unique insights on COVID-19 vaccination disparities that are hidden below the headline numbers. For instance, although Minnesota’s Black, Latino, and White populations each had similar COVID-19 vaccination rates (61 percent, 61 percent, and 65 percent, respectively) at the end of 2022, they took distinctly different paths to reach that point. Within six months of the first COVID-19 vaccine receiving emergency use authorization, Minnesota vaccinated half of the state’s White population, but it took twice as long (12 months) for the state to vaccinate half of its Black and Latino populations.

Another crucial but under-recognized factor in COVID-19 vaccination disparities is the way public health policies placed some groups as a disadvantage in accessing vaccines in the early days of limited supply. Because experience showed that elderly people were at higher risk of severe disease and death from COVID-19, they were prioritized to be among the first people eligible for vaccines. But nationwide and in Minnesota, the White population skews older, effectively baking racial and ethnic disparities into the vaccine prioritization criteria. For that reason, we also stratified racial and ethnic groups’ COVID vaccination data by age—an approach that uncovered complex dynamics.

We found that disparities in COVID-19 vaccination rates were relatively small among Minnesota’s elderly population. For instance, Minnesota succeeded in vaccinating half of the elderly population across all racial and ethnic groups within three or four months—an example of how health inequities can be minimized. But disparities were stark among young adults, age 19-24. While Minnesota vaccinated half of Asian and Native Hawaiian and Pacific Islander young adults within five months, it took roughly twice as long to vaccinate half of Latino young adults (nine months), White young adults (ten months), and Black young adults (eleven months). And stunningly, Minnesota had failed to reach half of American Indian and Alaska Native young adults by the end of 2022—approximately 24 months after vaccines were first authorized.

We also examined COVID-19 vaccination rates by other demographic categories, finding higher vaccination rates and quicker vaccination progress among older population groups, urban and suburban communities, and females. Additionally, our study found disappointing rates of COVID-19 vaccination among children, particularly younger children. At the end of 2022, less than one-half of children age 5-11 had been vaccinated, despite having been eligible for vaccines for over a year; and less than one-tenth of children age six months to four years had been vaccinated, despite having been eligible for roughly six months. Despite a common, incorrect notion that COVID-19 is harmless for children, other researchers have found that COVID-19 was a top 10 cause of death for children during the pandemic, so those low vaccination rates are needlessly leaving Minnesota kids at risk.

Together, the findings from this new study highlight two main points: First, Minnesota’s COVID-19 vaccination efforts resulted in clear disparities. When looking at high-level data, it is easy to miss those disparities because some of them narrowed over time. But looking at detailed data illustrates the ways that certain groups were left vulnerable to COVID-19 for much longer than others. Second, our findings on disparities in the time Minnesota took to vaccinate half of different subpopulations demonstrate the importance of monitoring such health equity measures over time. Time is critical in an emergency such as the pandemic, and eventually closing gaps in health disparities simply isn’t good enough. Health equity requires urgency.

Access the full issue brief on this analysis here.

Theis, Lindsey
Senior Communications Specialist

p 612-625-5062
e lani0058@umn.edu

Now Available on State Health Compare: One Brand New Measure and Five Updated Measures

Estimates for five measures of health care access, affordability, and use have now been updated on SHADAC’s State Health Compare. One new measure, Had Telehealth Visit, has also been added to State Health Compare. The new and updated measures are all produced using data from the National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS). SHADAC produces these state-level measures using restricted-access data through the Minnesota Research Data Center (MnRDC). SHADAC’s State Health Compare is the only source of state-specific data for these measures which are essential for monitoring individuals’ access to and use of medical care, along with their ability to afford care.

These measures now contain data through 2021, using two-year pooled periods (i.e., 2019-2020, 2020-2021). The measures can be broken down by Total, Age, and Coverage Type (Public, Private, Uninsured).

Updated and new measures include:

NEW: Had Telehealth Visit
This measure describes the percent of individuals who had a medical appointment by video or phone during the past twelve months.

Had Usual Source of Medical Care
This measure captures rates of individuals who had a usual place of medical care other than an emergency department during the past twelve months.

Had General Doctor or Provider Visit
This measure provides rates of individuals who had any visit to a general doctor or provider within the last year.

Had Emergency Department Visit
This measure looks at rates of individuals who had any type of visit to an emergency department in the past twelve months.

​Trouble Paying Medical Bills
This measure examines rates of individuals who had trouble paying off medical bills during past twelve months.

Made Changes to Medical Drugs
This measure highlights rates of individuals who were prescribed medication in the past twelve months who made changes to their medical drugs due to cost during the past twelve months. This includes delaying filling a prescription, taking less medicine, or skipping doses to save money.

Click here to explore these measures on State Health Compare!
 

Notes: Data for State Health Compare’s Had Dental Visit measure is only asked in the NHIS rotating core and thus was not asked in the 2021 survey. We will be able to update that measure with new data after both the 2022 and 2023 data are out in mid-2024.

All measures are representative of the civilian noninstitutionalized population.

Data Source: The estimates were produced using restricted NHIS data in the MnRDC. Measures have been updated with data through 2021 using two-year pooled periods, including (a) 2011–2012 through 2017–2018 and (b) 2019-2020 through 2020-2021, except in the case of the telehealth measure for which data is only available from 2020-2021.

Benedict, Maya
Research Assistant

e bened099@umn.edu

Monitoring Broadband Expansion and Disparities using Data from State Health Compare

Introduction

The onset of the COVID-19 pandemic underscored the importance of telehealth services to people across the U.S. and the crucial role of broadband internet access in providing those services. Telehealth continues to be a popular and often necessary way for patients to access care, and federal and state governments are now making significant investments to expand and ensure affordable access to broadband internet.¹

For these reasons, it is important to monitor changes in the share of the population with broadband internet as an indicator of access to care. SHADAC analysis of 2021 American Community Survey (ACS) data indicates households’ access to broadband internet has increased by 3.8 percentage points (PP) since 2019, rising to 90.1% (from 86.3%).

State Broadband Efforts

The percentage of households with broadband access varies across the states, ranging from a low of 81.8% in Mississippi to a high of 93.4% in Washington. Though every state experienced some increase in household broadband access, a few states showed larger expansions in access.

Out of all states, Arkansas saw the largest increase at 5.4PP, rising to 85.7% from 80.3%. Former Arkansas Governor Asa Hutchinson and the Arkansas General Assembly had made broadband a “top priority,” working to expand the state Broadband Office by increasing staffing and enhancing services.^2, 3 The state also developed the Arkansas Rural Connect (ARC) grant program to expand broadband access in rural communities, and they recently announced a first-in-the-nation partnership with national non-profit EducationSuperHighway to develop best practices and programs to address broadband affordability.⁴

Rates of broadband access increased by similar amounts in South Carolina, rising to 87.8% from 82.4%. South Carolina has engaged in significant broadband expansion initiatives over the past few years, approving nearly $30 million in broadband expansion projects in early 2021 and spending nearly $50 million in CARES Act funding on broadband-related projects in 2020.⁵

Despite gains in access, disparities by income level remain

Despite overall growth in broadband internet access, there are still sizable disparities in access between households of different income levels.

For example, though 91.1% of Minnesota households have broadband access (higher than the national average), only 73.1% of low-income households in Minnesota (under $25,000 per year) have broadband internet (below the national average of 74.7%).

In general, households with an income under $25,000 per year have the lowest percentage of broadband access, and households with an income over $50,000 per year have the highest percentage, though that difference varies by state. South Dakota shows the largest gap at 26.2PP: only 67.8% of low-income households have broadband access, compared to 94% of high-income households. Mississippi has a sizable disparity between income levels as well, with a 25.4PP difference between high- and low-income households.

Delaware and Oregon see the smallest disparities between income levels, showing a gap of only 15.8PP and 15.9PP between high- and low-income households, respectively. Those two states have some of the highest percentages of broadband access for low-income households as well, with 79.7% of low-income households in Delaware reporting broadband access and 79.5% in Oregon.

Considering these disparities, some states are taking steps to address broadband affordability;

The 2022 Virginia Telecommunication Initiative guidelines include grant scoring criteria that encourage applicants to be aligned with the state’s efforts to bring low-income households affordable access to broadband internet.⁶ 

The Minnesota Office of Broadband Development recently began the process of establishing a statewide digital equity plan which would focus on addressing internet service affordability and reducing gaps in device access, and digital skills.⁷ 

In 2021, California passed a historic law directing $6 billion toward improving broadband access and affordability, with multiple provisions intended to improve internet speed, increase access, and lower internet costs for consumers.^8, 9

Conclusion

On both national and state levels, access to broadband internet improved from 2019 to 2021. States have begun several promising broadband expansion initiatives and are using available federal and state grant funding to bolster broadband infrastructure and affordability. However, as states continue working toward greater broadband access and navigating an influx of funding for expansion projects, it is necessary to ensure those improvements are specifically targeted to address existing disparities in access.

About the Data
The data cited here can be accessed through SHADAC’s online data tool, State Health Compare, using the measure “Percent of households with a broadband internet subscription” for the years 2019-2021. The estimates come from SHADAC’s analysis of the American Community Survey (ACS) Public Use Microdata Sample (PUMS). All differences described are statistically significant at the 95% confidence level unless otherwise specified.