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Disparities in Health Insurance and Access to Care For Residents Across U.S. Cities

Executive Summary

U.S. metropolitan areas are characterized by pronounced disparities in rates of health insurance coverage and access to care. While it has been well documented that people with lower incomes run a greater risk of being uninsured than those with higher incomes, this study also finds a strong relationship between a city's rate of employer-sponsored health coverage and its overall rates of health coverage and access to care.

We examined health insurance coverage and access to health care among moderate- and low-income, nonelderly residents of the nation's largest metropolitan areas. Our key findings are:

  • There is great variation in uninsured rates across U.S. cities, ranging from a high of 37 percent in El Paso, Texas, to a low of 7 percent in both Akron, Ohio, and Harrisburg, Pennsylvania.
  • There is great variation in rates of employer-based health coverage across cities, from 84 percent in Milwaukee, Wisconsin, to just 49 percent in El Paso, Texas.
  • Those with lower incomes are especially at risk. Among residents with incomes below 250 percent of the poverty level, uninsured rates vary from 11 percent in Honolulu to 50 percent in El Paso.
  • The uninsured are much less likely to have a regular source of health care or to have seen a physician in the last year; they are also much more likely to delay seeking care.
  • Residents of cities with high uninsured rates generally have a harder time getting the health care they need than those living in cities with relatively low uninsured rates. The negative impact of high uninsured rates affects individuals with moderate incomes well above the poverty level.

The study found wide variation in health insurance coverage in cities across the United States. The average uninsured rate for the 85 MSAs studied is 19 percent, with 12 of the communities having significantly higher rates (25% to 37%) and 27 having significantly lower rates (7% to 14%). The 12 MSAs with higher-than-average uninsured rates are located in Arizona, California, Florida, New Jersey, New York, and Texas, all of which have large concentration of immigrants, including both naturalized citizens and noncitizens. In these cities, Latinos comprise a large proportion of the moderate- and low-income immigrant residents. The 27 MSAs with lower than average uninsured rates are more geographically diverse, although they are generally clustered in the northern half of the United States.

Not surprisingly, many of the cities with the highest uninsured rates also have the lowest rates of employer-based health coverage. The MSAs with the lowest rates of job-based insurance are all located in Arizona, California, Florida, New Jersey, New Mexico, New York, and Texas. Low-coverage MSAs have lower proportions of residents living in families with at least one fulltime, full-year employed adult and higher proportions of breadwinners working in firms with fewer than 10 employees. These employment situations are less likely to offer workers job-based health benefits. Low-coverage communities also have higher unemployment and poverty rates and larger proportions of the population living in single-parent-headed households. Families with more working adults have more potential for access to job-based insurance.

No matter where they live, people with moderate and low incomes are much less likely than more affluent people to have job-based coverage. The disparity is generally greater, however, among the less advantaged living in low-coverage areas—particularly Latinos and noncitizens.

Medicaid provides coverage for many moderate- and low-income families with children who do not have access to affordable job-based insurance. To a large degree, MSAs with high rates of Medicaid coverage share the same characteristics as those with low rates of job-based insurance. The average Medicaid rate for the 85 MSAs is 8 percent. In high Medicaid-coverage areas, fully one-third (33%) of the residents rely on Medicaid.

People without health insurance generally have less access to medical care than those with coverage, especially moderate- and low-income individuals who cannot afford out-of-pocket expenses for care. This study found wide variation in access to care among this population across 29 MSAs on three important measures: lack of a usual source of care, delaying care or going without needed care in the past year, and not having a physician visit in the past year.

Uninsured at High Risk for Lack of Access to Care
Within each MSA, low- and moderate-income residents without health insurance have less access to needed medical care than those of similar income with insurance. Regardless of whether the city has a higher- or lower-than-average uninsured rate, residents without coverage are less likely to have a regular source of care, more likely to have delayed or forgone needed care, and less likely to have seen a physician during the year.

The contrast between the experiences of the uninsured and insured are typically stark. For example, 40 percent of uninsured residents in Detroit and 61 percent in Los Angeles report having no regular source of care, compared with only 6 percent and 8 percent, respectively, of their insured counterparts. Among nearly all the cities with an adequate sample size for access-to-care measures, the uninsured were twice as likely not to have visited a physician.

The socioeconomic characteristics of a community affect its job-based insurance rate and its uninsured rate. An area's uninsured rate, however, is also affected by public policy. Given similar demographics and economic conditions, a particular community is likely to have a lower uninsured rate if the state in which it is situated has relatively more generous eligibility requirements for Medicaid and other public health insurance programs.

Cities and counties have limited ability to address their residents' lack of access to employment-based health insurance. Long-term efforts may increase the proportion of residents working and the proportion of employed full-time, but cities and counties may lack the resources or authority to require small employers to offer health benefits or to mandate that employers make their employees' share of health insurance premiums affordable for moderate- and lowincome workers. States, on the other hand, have expanded opportunities to cover uninsured children and their families. States can now cover working parents of children eligible for Medicaid using the family coverage options provided by section 1931 of the Social Security Act. The federal Children's Health Insurance Program (CHIP) provides additional opportunities and funding to extend coverage to children in working families with incomes up to 250 percent of the poverty level or higher.

Some states have used state tax resources or leveraged them with federal funds through Medicaid section 1931 options, CHIP eligibility, and/or Medicaid section 1115 waivers. States can use section 1931 to cover working families, including adults, above traditional Medicaid income eligibility levels. States can also use section 1115 waivers to modify Medicaid's federal eligibility requirements and use their funds to cover more groups, such as adults without children, than would qualify under traditional Medicaid provisions. These policies and programs can reduce uninsured rates in the states and in their urban areas.

In the absence of universal coverage, moderate- and low-income urban residents will continue to experience barriers to needed health care. Cities and counties will bear the responsibility of providing for at least their minimum needs. Although many community-based hospitals and clinics meet some of their expenses through charitable contributions, local governments and community foundations can provide substantial support to these local safety net systems. States and the federal government can help these communities by providing more adequate financial support to the health care safety net, reducing the barriers found in areas with higher-than-average uninsured rates.

Publication Details



E. R. Brown, R. Wyn, and S. Teleki, Disparities in Health Insurance and Access to Care For Residents Across U.S. Cities, The Commonwealth Fund, August 2000