Racial Disparities in Cost and Non-Cost Barriers to Care: An Analysis of the All of Us Survey

INTRODUCTION

Racial and ethnic disparities in healthcare remain significant challenges in the USA.¹ Considerable differences persist in barriers to care and patient outcomes.^2,3 The All of Us (AoU) Research Program was established by the National Institutes of Health with the goal of recruiting one million socially diverse participants.⁴ We aim to further understand self-reported cost- and non-cost associated barriers to care and medications that racial and ethnic minorities face in the USA.

METHOD

This cross-sectional study analyzed survey data from AoU (2017–2022), with a focus on questions related to barriers to accessing medical care and medications. Patients of multiple races/ethnicities were not included in this study due to lack of granular information. Data analyses were conducted in the AoU Researcher Workbench using Jupyter Notebook software and Python (version 3.12.1). A two-sided P < 0.05 was considered statistically significant. Multivariable logistic regression was adjusted for a priori covariates including sex, foreign born, and income.

RESULTS

Our study included 393,043 participants, of which 20% were Black, 19% were Hispanic, 4% were Asian, and 4% reported more than one race (Table 1). Compared to White participants, Black and Hispanic participants had lower household income, less likely to be married, have private insurance, or college degrees, all p < 0.001.

Table 1.

Demographics and Characteristics of the Study Population

	White	% or St Dev	Black	% or St Dev	P value	Hispanic	% or St Dev	P value	Asian	% or St Dev	P value
Total	226,615	57.7%	78,321	19.9%		73,945	18.8%		14,162	3.6%
Age	53.3	17.1	49.0	14.7		44.0	15.8		42.1	16.8
Sex
Female	138,258	61.0%	45,147	57.6%	< 0.001	49,306	66.7%	< 0.001	8504	60.0%	0.02
Male	86,678	38.2%	31,892	40.7%		24,018	32.5%		5564	39.3%
US vs Foreign Born
US	214,694	94.7%	73,384	93.7%	< 0.001	38,043	51.4%	< 0.001	5042	35.6%	< 0.001
Foreign	10,570	4.7%	3910	5.0%		35,420	47.9%		9073	64.1%
Insurance
Private	120,537	53.2%	18,482	23.6%	< 0.001	22,738	30.7%	< 0.001	9760	68.9%	< 0.001
Medicare	52,212	23.0%	12,118	15.5%		7246	9.8%		1426	10.1%
Medicaid	26,564	11.7%	29,479	37.6%		25,341	34.3%		1366	9.6%
Other	17,738	7.8%	4049	5.2%		3147	4.3%		456	3.2%
Marital Status
Married or Living with Partner	134,405	59.3%	19,637	25.1%		35,495	48.0%		7644	54.0%
Divorced or Separated	35,739	15.8%	17,429	22.3%	< 0.001	13,712	18.5%	< 0.001	999	7.1%	< 0.001
Never Married	41,995	18.5%	32,748	41.8%	< 0.001	19,509	26.4%	< 0.001	4932	34.8%	< 0.001
Widowed	11,977	5.3%	4477	5.7%	< 0.001	2740	3.7%	< 0.001	317	2.2%	< 0.001
Income
< 10 K	15,758	7.0%	25,016	31.9%	< 0.001	11,900	16.1%	< 0.001	891	6.3%	< 0.001
10–35 K	36,349	16.0%	18,492	23.6%		16,941	22.9%		1698	12.0%
35–75 K	50,413	22.2%	9443	12.1%		11,051	14.9%		2576	18.2%
75 K–150 K	59,439	26.2%	4369	5.6%		6186	8.4%		3289	23.2%
> 150 K	38,096	16.8%	1455	1.9%		2586	3.5%		2797	19.8%
Education
<  = Grade 11	6051	2.7%	11,477	14.7%	< 0.001	17,593	23.8%	< 0.001	254	1.8%	< 0.001
HS/GED	28,831	12.7%	26,310	33.6%		18,163	24.6%		957	6.8%
College	58,350	25.7%	21,906	28.0%		18,512	25.0%		1973	13.9%
Advanced Degree	131,164	57.9%	15,163	19.4%		17,491	23.7%		10,769	76.0%

Cost-Associated Barriers

After adjusting for age, sex, education, and income, Black and Hispanic patients were more likely to seek care from emergency departments (Black aOR 3.83, 95% CI 3.51–4.18; Hispanic aOR 2.49, 95% CI 2.22–2.78), delay care from a generalist (Black aOR 1.67, 95% CI 1.58–1.77; Hispanic aOR 1.72, 95% CI 1.62–1.82), and delay follow-ups (Black aOR 1.49, 95% CI 1.41–1.57; Hispanic aOR 1.55, 95% CI 1.47–1.65). Black patients were also more likely to delay medication refills (aOR 1.09, 95% CI 1.04–1.15) and skip medications (aOR 1.10, 95% CI 1.04–1.16) due to cost concerns. Asians were more likely to delay care from generalist (aOR 1.2, 95% CI 1.1–1.3), but less likely to seek care from emergency departments (aOR 0.67, 95% CI 0.48–0.93) or delay refills (aOR 0.89, 0.80–0.98) (Table 2).

Table 2.

Cost and Non-Cost Associated Barriers to Care Among Racial/Ethnic Minorities, Adjusted for Sex, Foreign Born, and Income

	White	Black				Hispanic				Asian
	Reference	aOR	95% low	95% high	P value	aOR	95% low	95% high	P value	aOR	95% low	95% high	P value
Places to get care—emergency room	-	3.83	3.51	4.18	< 0.001	2.49	2.22	2.78	< 0.001	0.67	0.48	0.93	0.02
Cost-associated barriers
Delayed generalist care due to cost	-	1.67	1.58	1.77	< 0.001	1.72	1.62	1.82	< 0.001	1.19	1.06	1.33	0.004
Delayed specialist care due to cost	-	0.97	0.93	1.01	0.16	1.02	0.98	1.07	0.38	1.16	1.08	1.25	< 0.001
Delayed follow-up care due to cost		1.49	1.41	1.57	< 0.001	1.55	1.47	1.65	< 0.001	1.02	0.92	1.15	0.67
Delayed filling prescription due to cost	-	1.09	1.04	1.15	< 0.001	0.96	0.91	1.01	0.14	0.89	0.8	0.98	0.02
Skipped medication due to cost	-	1.1	1.04	1.16	< 0.001	0.98	0.92	1.05	0.6	0.94	0.83	1.06	0.28
Non-cost associated barriers
Delay in care—no time off work	-	1.15	1.09	1.22	< 0.001	1.7	1.62	1.78	< 0.001	1.98	1.84	2.13	< 0.001
Delay in care—no transportation	-	1.57	1.49	1.65	< 0.001	1.45	1.37	1.54	< 0.001	1.17	1.04	1.31	0.008
Delay in care—no childcare	-	1.25	1.14	1.37	< 0.001	2.1	1.94	2.29	< 0.001	1.11	0.95	1.31	0.19
Delay in care—no elder care	-	1.14	1.02	1.26	0.02	1.46	1.32	1.63	< 0.001	0.91	0.73	1.13	0.4
Delay in care—living in rural area	-	0.92	0.85	0.99	0.04	1.14	1.05	1.25	0.003	0.59	0.48	0.73	< 0.001

Non-Cost Associated Barriers

Non-White individuals were more likely to delay care due to lack of time off work (Black aOR 1.15, 95% CI 1.09–1.22; Hispanic aOR 1.70, 95% CI 1.62–1.78; Asian aOR 1.98, 95% CI 1.84–2.13) and lack of transportation (Black aOR 1.57, 95% CI 1.49–1.65; Hispanic aOR 1.45, 95% CI 1.37–1.54; Asian aOR 1.17, 95% CI 1.04–1.31). Black and Hispanic individuals were more likely to delay care due to lack of childcare (Black aOR 1.25, 95% CI 1.14–1.37; Hispanic aOR 2.10, 95% CI 1.94–2.29) and elder care (Black aOR 1.14, 95% CI 1.02–1.26; Hispanic aOR 1.46, 95% CI 1.32–1.63). Hispanic individuals are also more likely to delay care due to living in rural areas (aOR 1.14, 95% CI 1.05–1.25).

DISCUSSIONS

This study highlights the pervasive nature cost and non-cost barriers faced by minority populations. Black and Hispanic patients are more likely to utilize emergency departments and delay care due to cost. Previous research also found minority groups have less access to primary care and preventive services, leading to an overreliance on emergency care.⁵ Interestingly, Asian participants were more likely to delay care but less likely to seek emergency care or delay medications, possibly suggesting distinct barriers or cultural preferences in healthcare utilization.

Similar to prior findings, non-cost barriers such as finding time off work and lack of transportation were ubiquitous within minority groups.¹ Addressing financial barriers alone may not sufficiently improve access for these populations. Further strategies must be implemented to enhance access to medical care, such as offering extended hours, telehealth services, and transportation assistance. Additionally, while it is crucial to address these barriers, further studies are needed to evaluate how these barriers impact outcomes for these individuals.

Limitations

Although the AoU Program aims to recruit a socially diverse cohort, there may still be sampling biases that impacts the generalizability of the results. Additionally, this survey lacks information such as the extent or duration of delay in care or medications.

CONCLUSION

Racial/ethnic minority populations continue to face cost, structural, and societal barriers to obtaining care. It is imperative for policy makers, providers, and community leaders to identify these impediments and to address these with targeted strategies to optimally promote health equity.

Declarations:

Conflict of Interest:

ABJ received consulting and speaking for Salix Pharmaceuticals, consulting for Dynavax Therapeutics, and speaking for Madrigal Pharmaceuticals. XY, RZ, SP, NN, RR, and CL have no financial conflicts to report.