Health and Health Insurance in Identifying barriers to accessing health care

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Only 8.7 percent of Detroit residents lack health insurance according to a 2018 survey conducted by the University of ’s Detroit Metro Area Communities Study (DMACS). This represents a substantial drop in the fraction of Detroiters without insurance. As of 2013 – the year before the Affordable Care Act implemented – American Community Survey data found that 19.4 percent of Detroit residents uninsured.

Despite the large number of Detroit residents who have health insurance, many still face barriers to accessing health care. According to the 2018 DMACS survey, nearly 10 percent of Detroit residents report being unable to afford a copayment or prescription in the last 12 months, while another third report that they have been unable to access one or more types of desired health care  especially dental care  in the past 12 months. These barriers are even more pronounced among people who lack health insurance. Three out of every five Detroiters without health insurance report being unable to access the health care they desire and nearly a quarter report being unable to afford care in the last 12 months.

The survey also reveals important health disparities within the ’s population related to racial and economic inequality. For example, the city’s African-American residents and residents of a lower socio-economic status report lower levels of health than other residents and are significantly more likely to use emergency rooms as their primary place of care.

These results highlight some of the findings from DMACS’ Summer 2018 survey, developed in partnership with the Detroit Health Department. The survey examined city residents’ experience with and access to health care and other aspects of their health and well- being. These surveys, collected between June and October 2018 from a representative sample of 1,206 Detroit residents, provide new insights into the health status and barriers to health affecting Detroiters.

Key Findings

A majority of Detroiters have health insurance, but some groups are

disproportionately uninsured.

Following the implementation of the Affordable Care Act (ACA) in 2014, the number of Americans without health insurance dropped precipitously.1 In Michigan, estimates suggest that 1.2 million residents gained access to health insurance through expanded insurance programs from the ACA.2 In Detroit, the number of uninsured fell by more than half since 2013, when 19.4 percent of Detroiters were

1 Kaiser Family Foundation. December 2018. Key Facts about the Uninsured Population. Accessed at: https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/ 2 Reindl, JC. November 1, 2018. “How Obamacare has affected Michigan 5 years after rollout.” . Accessed at: https://www.freep.com/story/money/2018/11/01/affordable-care-act-obamacare-michigan/1807230002/

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uninsured according to the American Community Survey. As shown in Figure 1, 91.3 percent of Detroit residents were covered by some form of health insurance in 2018, while 8.7 percent report having no health insurance.


Detroiters’ Health Insurance Coverage

Nearly one third (31.8%) of insured Detroiters receive health care coverage through their job or through school, while 8.7% more than half are insured through a government insurance program, as shown in Figure 2. Of those insured through a government program, most (31.1%) are covered by Medicare , which provides Insured insurance for Americans 65 and older and Uninsured for those with some disability status, while 22.5 percent of Detroiters with health insurance are insured through Healthy Michigan, the state’s Medicaid option that 91.3% expanded following the passage of the Affordable Care Act. Ten percent of insured Detroit residents purchase health insurance through a health exchange or directly from an insurance provider.


Health Insurance Provider for Insured Detroiters

MIChild (CHiP), the VA, or some other source 5.0%

Purchase health insurance through a health 9.7% exchange or directly from an insurance provider

Healthy Michigan (Medicaid) 22.5%

Medicare 31.1%

Private health insurance through a job or school 31.8%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%

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Detroiters under age 55 are most likely to be uninsured.

Detroiters under the age of 55 are significantly more likely residents and 6.9 percent of Black residents. Employment than older residents to be uninsured.3 Roughly one in eight status was another source of disparities in health care (12.2%) residents aged 18 to 34 report no insurance coverage, coverage. Roughly a fifth (21.0%) of people employed part- compared to less than five percent of those 55 and older. time lack health insurance, but this fraction is lower among Additionally, nearly a quarter (22.0%) of Hispanic residents those employed full-time (7.8%), those who are currently report lacking insurance, compared to 11.2 percent of White unemployed (8.2%), and those who are retired (1.5%).


Demographics of Uninsured Detroiters, by Age, Race/Ethnicity, and Employment Status

Unemployed 8.2% 91.8%

Retired 1.5% 98.5% Part-Time 21.0% 79.0%


Full-Time 7.8% 92.2% Hispanic 22.0% 78.0%

Black 6.9% 93.1%

White 11.2% 88.8% Race/Ethnicity 65+ 5.7% 94.3% 55-64 3.0% 97.0%

Age 35-54 10.5% 89.5%

18-34 12.2% 87.8% Uninsured Insured 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

3 Unless otherwise noted, descriptive analyses comparing group means throughout this report represent statistically significant differences at the 95% confidence level.

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Most Detroiters report being in good health, but there are significant disparities in health levels.


Detroit Residents’ Self-Reported Health Score

Poor 4%

Fair 18%

Good 28%

Very Good 28%

Excellent 22%

0 0.05 0.1 0.15 0.2 0.25 0.3

Figure 4 summarizes Detroiters’ self-reported health status. health, while only 10.8 percent of White Detroiters report One in five (22.3%) report being in fair or poor health, which is similarly low levels of health. More than a quarter of all high compared to statewide and national estimates from the females (27.2%) report being in poor health compared to 17.3 Centers for Disease Control that found that 18.4 percent of percent of men. Those with lower levels of educational Michiganders and 17.6 percent of US residents reported being attainment and those who are low income are also more likely in fair or poor health in 2017.4 One in five Detroiters report to report being in poor health. In fact, a third of those who that they are in excellent health, while more than half (56.2%) earn $30,000 or less a year report being in poor health. Only of Detroiters state their health is good or very good. four percent of those who have lived in Detroit for fewer than five years report being in poor health, while nearly a quarter There are also striking disparities between Detroiters who (24.6%) of longer-term residents (those who have lived in report being in fair or poor health compared to those who Detroit for more than five years) report their health is fair or report being in good or excellent health, as captured in Figure poor. 5. A quarter of Black Detroiters report being in fair or poor

4 BRFSS Prevalence & Trends Data. Centers for Disease Control and Prevention. Accessed at: https://www.cdc.gov/brfss/brfssprevalence/

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Demographics of Detroiters who Report Being in Fair or Poor Health

20+ Years 26.6% 55.2% 18.2% 6-20 Years 13.8% 59.5% 26.6% Tenure 0-5 Years 4.0% 60.9% 35.1% $60,000+ 7.2% 61.7% 31.1% $30,000 - $59,999 13.9% 62.9% 23.2%

$10,000 - $29,999 29.3% 56.6% 14.2% Income Less than $10,000 34.8% 48.2% 17.0% College + 10.3% 59.6% 30.2% Some College or Associate's Degree 20.6% 62.2% 17.2%

Education High School or Less 29.1% 51.6% 19.3% Female 27.2% 54.7% 18.2%

Male 17.3% 57.9% 24.9% Gender Hispanic 14.8% 58.8% 26.5%

Black 24.7% 55.4% 19.9% Race White 10.8% 62.7% 26.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Fair or Poor Good or Very Good Excellent

Nearly one fifth of Detroiters rely on the emergency room as their typical place of care.

Most Detroiters (85.3%) report having a typical place they go when they are sick. The majority (57.3%) of Detroiters who have a regular place of health care go to a doctor’s office, while 10.3 percent utilize a health center clinic, 6.8 percent utilize urgent care clinics, and 6.1 percent utilize a hospital outpatient department. Nearly one in five Detroiters (17.2%) report that they typically go to the hospital emergency room when they feel sick, and this is even more common among those who lack health insurance.


Primary Sources of Health Care for Detroiters with a Usual Place of Care When Sick

Hospital Outpatient Department 6.1% Other Urgent Care Clinic 6.8% Hospital Emergency Room 17.2% Doctor's Office 57.3% Clinic or Health Center 10.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

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As shown in Figure 7, about two-fifths (41.9%) of Detroiters Detroiters making $10,000 or less and those with lower who lack health insurance and nearly one-third (28.5%) of educational attainment are significantly more likely to turn to Detroiters who report being unable to access one or more the ER for care than other city residents. Additionally, one-fifth types of health care in the last 12 months turn to the ER as (19.8%) of the city’s Black residents report using the ER as their their typical place of care. The ER also serves as the typical typical place of care. place of care for less socio-economically advantaged residents.


Use of Hospital ER as Usual Place of Care When Sick

Ever Unable to Access Care 28.5%

Uninsured 41.9%

Insured 15.9% Insurance $60,000+ 4.7%

$30,000 - $59,999 12.9%

Income $10,000 - $29,999 17.6%

Less than $10,000 26.5%

College + 9.4%

Some College or Associate's Degree 13.2%

Education High School or Less 23.2%

Hispanic 14.2%

Black 19.8% Race White 2.4%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%

While most Detroiters are able to access a type of medical care they desire, unmet demand for dental care is high.

Most Detroiters report that they have been able to access the only 8.3 percent were not able to get care they needed from type of medical care they wanted in the past year. For other types of doctors (i.e., specialists) in the past year. Figure example, only 6.3 percent of Detroiters were not able to 8 provides more detailed results on the unmet demand for obtain care they needed from a primary care physician, and health care.

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Detroiters’ Access to Health Care, by Care Type

Holistic Medicine 13.3% 78.2% 8.5%

Family planning 11.5% 85.0% 3.5%

Dental Care 29.1% 56.6% 14.2%

Substance Abuse Care 6.5% 91.0% 2.5%

Mental Health Care 15.5% 76.2% 8.3%

Physical Therapy 21.6% 72.2% 6.2%

ER 35.4% 59.4% 5.1%

Specialist 54.3% 37.5% 8.2%

Primary Care 70.4% 19.1% 6.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Able to Access Care Didn't Want Unable to Access

Nearly three out of ten Detroiters (29.1%) report that they dental insurance as lack health insurance.5 In addition to have not been able to access at least one type of desired dental care, 8.3 percent of Detroiters report being unable to health care in the past 12 months. The greatest unmet access desired mental health care. These unmet medical demand is for dental care. One out of every seven Detroiters needs may reflect systemic shortages in care in Wayne County. (14.2%), report that they wanted but were unable to access The Department of Health and Human Services has dental care in the past 12 months. This gap is likely due to the designated multiple areas within Wayne County, including the fact that dental coverage isn’t typically included in health city of Detroit, as medically underserved areas, specifically insurance plans, including Medicaid and Medicare. National lacking dental and mental health professionals.6 data suggests that nearly three times as many Americans lack

5 National Association of Dental Plans. “Who has dental 6 Michigan Department of Health and Human Services. “Where benefits today?” Accessed at: are Michigan's Designated Shortage Areas?” Accessed at: https://www.nadp.org/dental_benefits_basics/dental_bb_1.asp https://www.michigan.gov/mdhhs/0,5885,7-339- x 71551_2945_47514-176079--,00.html

Affordability is the greatest barrier to care, especially for those without insurance.

Results from DMACS also shed light on barriers to receiving health care in Detroit. Over one-quarter (28.1%) of Detroit residents report facing some barrier to receiving health care in the past year. Figure 9 shows that the most common barriers to receiving care are related to insurance and affordability issues. Care not being covered by insurance was a barrier for 9.0 percent of residents. Nearly 10 percent of residents experienced some affordability issue as a barrier to care. Fear of doctors and language barriers are relatively uncommon barriers to medical care. Further, as shown in Figure 10, few Detroiters (6.63%) report that they have encountered unfair treatment on the basis of race, age, gender, or some other form of bias by their health care provider in the past 12 months.


Percent of Detroiters Experiencing Some Barrier to Accessing Medical Care

Language 1.2%

Fear 3.5%

Couldn't Find Services 3.3%

Service Not Covered by Insurance 9.0%

Unaffordable Prescription 7.4%

Unaffordable Copayment 4.4%

No Insurance 6.3%

Inconvenient 5.6%

Transportation 5.3%

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0%

However, Detroiters without health insurance report access. Similarly, lack of health insurance increases the significantly higher barriers to health care. As shown in Figure likelihood that Detroiters will be unable to afford health care. 11, 61.0 percent of residents who lack health insurance report One fifth (20.9%) of those who lack health insurance report that in the last 12 months they were unable to access one or being unable to afford a copayment or prescription in the last more types of health care they desired, while only 26.3 12 months, while only 8.7 percent of those with health percent of those with health insurance report the same lack of insurance report the same affordability issues.

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Percent of Detroiters Experiencing Some Form of Discrimination by a Health Care Provider

One or More Types of Discrimination 6.63%

Other Discrimination 1.34%

Age Discrimination 1.88%

Gender Discrimination 1.28%

Racial Discrimination 3.08%

0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00%


Barriers to Accessing and Affording Health Care for Insured and Uninsured Detroiters

70.0% 61.0% 60.0%



30.0% 26.3% 20.9% 20.0% 8.7% 10.0%

0.0% Unable to Access Desired Health Care Unable to Afford Health Care

Insured Uninsured


We are grateful for the generous financial support of the Detroit Health Department, the , and Poverty Solutions at the . We also benefited from the advice and expertise of the Institute for Social Research’s Survey Design Group and Survey Research Operations. This report was written by Lydia Wileden and is a collaborative effort of numerous colleagues and stakeholders, including Dr. Elisabeth Gerber, Dr. Jeffrey Morenoff, and Sharon Sand.

For more information

Please contact Sharon Sand, DMACS project manager, at [email protected] or 734-647-1775

Support for DMACS comes from the University of Michigan Gerald R. Ford School of Public Policy, Institute for Social Research and Poverty Solutions. DMACS is also supported by the Knight Foundation.

Learn more at www.detroitsurvey.umich.edu

The Regents of the University of Michigan Jordan B. Acker, Huntington Woods, Michael J. Behm, Grand Blanc, Mark J. Bernstein, Ann Arbor, Paul W. Brown, Ann Arbor, Shauna Ryder Diggs, , , Bingham Farms, Ron Weiser, Ann Arbor, Katherine E. White, Ann Arbor, Mark S. Schlissel (ex officio)

The University of Michigan is a Non-discriminatory, Affirmative Action Employer. © 2019 Regents of the University of Michigan