CHIPS Policy Brief

August 2021

Overcoming Barriers Health status is

to Access Health Care determined by

many factors, one
The Challenges Facing Minorities and of which is access to
Immigrants in Washington State
health care. What
Layla G. Booshehri, PhD, Jerome Dugan, PhD
can Washington
state do to reduce
disparities in access
experienced by
BIPOC and immigrant
communities?

Key Points:
The Center for Health Innovation
• Washington state’s Black, Indigenous, and People of Color & Policy Science (CHIPS) is an
(BIPOC) and immigrant communities face worse health interdisciplinary research center
that works to improve health across
outcomes and a lower standard of care compared to their
communities and the lifespan
white counterparts. through innovation, evaluation,
and training in health policy and
• Barriers to access, both at the individual and system levels, are
health systems science, with a focus
the primary drivers for inadequate care and unmet needs. on health equity.
• As a purchaser and regulator, the state and its agencies Director
can exercise their authority to finance, implement, and David Grembowski, PhD
oversee interventions to help reduce and/or eliminate
Associate Director
systemic barriers that disproportionately affect minority and Layla G. Booshehri, PhD
immigrant households.

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Summary of Issues
Black, Indigenous, and People of Color (BIPOC) and immigrant
communities in Washington state and the nation not only seek
and receive health care services at lower rates than whites but
also receive care of lesser quality compared to whites. Researchers
have documented that the delay, avoidance, and receipt of low-
quality care can lead to poorer health outcomes as measured by
morbidity and mortality. It is no surprise, therefore, that BIPOC and
immigrant communities across Washington state, and the nation as
a whole, report worse health than their white counterparts.

The reasons behind these disparities are more complex than

previously documented. They are attributable not only to an
individual’s personal and social obstacles but also to the policies,
practices, or attitudes of institutions that impede BIPOC and
immigrant populations from enjoying low-barrier access to
health- and welfare-promoting services. Figure 1 summarizes Figure 1
the social determinants of
health status and common Barriers to Access Healthcare
Social Determinants of Health

barriers to access health Economic Stability

Supply side
care. Barriers to health Community & Geographic maldistribution
care access include both Social Context Financial maldistribution
supply- and demand-side Narrow provider networks
factors that primarily Education Bias (explicit, implicit)
originate from constraints Restrictive hours
at the institutional and Healthcare
policy levels. Demand side
Unaffordability
Food
Lack of insurance
Reducing disparities
Inadequate knowledge
in health and health Neighborhood &
Reluctance to seek care
care has been a priority Physical Environment
Inadequate transportation options
for Washington state’s
executive and legislative branches for the last four decades.
Although Washington state has a strong track record in narrowing
health disparities, those between white and BIPOC and immigrant
communities continue to persist. This is due, in part, to the
fact that barriers can vary substantially across individuals,
communities, and geographies, necessitating a systematic plan of
action to address their root causes.

The purpose of this policy brief is to (1) summarize the health and
health care disparities facing BIPOC and immigrant communities
in Washington state, (2) describe the major barriers to health
care access these groups face, (3) discuss current state efforts
to reduce disparities, and (4) provide guidance for ongoing and
planned interventions.

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Health Disparities in Washington State

Washington is a diverse state, home to over 7.7 million residents In Washington state,
and 29 federally recognized tribes spread across 39 counties.
all-cause mortality
BIPOC residents currently represent 20% of Washington state’s
population and, according to the state’s Office of Financial is substantially
Management, will grow to nearly 30% by 2040.1 A report from the
American Immigration Council notes that immigrants make up 15% higher for some
of Washington state residents.2 Mirroring national trends, BIPOC
BIPOC communities
populations will constitute a majority of the state’s population
over the next few decades. The disparities BIPOC and immigrant compared to whites.
populations face in access to care will persist in the future in the
absence of more aggressive policy action.

Rates of communicable and noncommunicable diseases are one

example of disparities in morbidity and mortality in Washington
state. For example, the COVID-19 communicable disease
pandemic has resulted in high rates of infections and death,
with Hispanic households being disproportionately affected.
While Hispanics account for 13% of Washington’s population,
this community had 31% of all COVID-19 cases and 23% of all
COVID-19-related hospitalizations as of March 2021.3 Across a
broad range of noncommunicable disease categories, data from
the Behavioral Risk Factor Surveillance System (BRFSS) show that
BIPOC populations have a higher prevalence of arthritis, asthma,
cardiovascular disease, COPD, depression, diabetes, and renal
disease than whites.4

All-cause mortality is also substantially higher for some BIPOC

communities compared to whites: 692.2 per 100,000 persons for
whites versus 771.1 for Blacks and 893.6 for American Indians and
Alaska Natives.5 A study led by researchers at Washington State
University documented that between 2011 and 2017, opioid-only
mortality increased among American Indians, Alaska Natives, and
Hispanics.6 Furthermore, American Indians and Alaska Natives
reported the highest alcohol-only, opioid-only, and co-use mortality
across all racial/ethnic groups.

These findings demonstrate that BIPOC and immigrant

communities face significant individual and collective burden of
disease attributable to disparities.

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Barriers to Access Care

In addition to significant disparities across diseases, BIPOC and immigrant communities systematically
report lower health insurance coverage rates and use and availability of services as well as higher costs
of health care services than their white counterparts. Although access barriers are numerous and
interrelated, which can be present on both the demand- and supply-sides of the health care marketplace,
researchers have identified several notable barriers as important in explaining health and health care
disparities among BIPOC and immigrant communities.

• Geographic maldistribution. Although shortages in the health care workforce will be a significant
challenge over the next decade, it is the geographic maldistribution of medical facilities and physician
workforce that presents an immediate barrier for patients. The concentration of medical facilities and
physician workforce in urban, suburban, or affluent areas can leave socioeconomically vulnerable
populations with inadequate access to health care services. In addition to a well-documented divide in
health care professionals between urban and rural areas, significant disparities exist across federally
designated health professional shortage areas (HPSA), medically underserved areas/populations
(MUA/P), and rural areas.

• Financial maldistribution. A higher proportion of BIPOC and immigrant communities rely on public
programs such as Medicaid, which commonly pay providers less than private insurers. As a result,
many providers limit how many beneficiaries of these programs they will see, sometimes leading to
severe barriers to access services, notably for mental health, dental, and other specialty care. Low
payment rates may lead some care providers to relocate to communities where the dominant form of
coverage reimburses at a higher rate, and this can further exacerbate geographic maldistribution.7,8

• Restricted provider networks. In an effort to design more affordable health insurance plans,
insurers have designed offerings with limited networks of providers. Insurers are often able to
negotiate better reimbursement terms by directing patients to narrower and less costly provider
networks. This strategy, however, has two unintended consequences. First, if a health plan includes
too few providers, beneficiaries may have to travel excessive distances to receive care. Second, when
networks are too narrow, beneficiaries may be forced to use out-of-network care, which can lead to
unaffordable or unavailable care.9

• Racial bias. Both explicit bias (overt discrimination, racism) and implicit bias (unconscious prejudice)
among providers have been shown to harm health and further exacerbate health disparities among
socioeconomically vulnerable populations. These biases degrade trust in the patient-provider
relationship, which in turn contributes to poor clinical outcomes.10–13

• Limited appointment availability. Providers who restrict hours or do not offer after-hours care
impede individuals’ ability to seek timely care.14 In a recent Washington Health Care Authority (HCA)
report, patients identified a lack of clinics with extended hours, long wait times for child visits, and
lack of appointment time slots for families with multiple children as major access challenges.15 Many
patients reported that standard hours of operation do not easily accommodate parents’ work and
children’s school schedules. BIPOC and immigrant communities are particularly affected by these
factors.

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• Lack of affordability. According to the Peterson-Kaiser Family Foundation Health System Tracker,
10.5% of adults report delaying or not getting care because of health care costs. When broken down
by race, 15.5% of Hispanics, 13% of non-Hispanic Blacks, and 9.4% of non-Hispanic whites report
delaying/avoiding care due to costs.16 Moreover, patients with a lower health status (19.4%) reported
costs as a barrier at a higher rate than healthier respondents (8.9%). The uninsured reported cost as a
barrier at a much higher rate (36.5%) compared to the insured (5.2%).

• Inadequate insurance coverage. Health insurance coverage is the primary mechanism to finance
health care services in the U.S. Therefore, missing or inadequate health insurance coverage
makes people more likely to avoid using services for disease prevention, treatment or recovery, or
appropriate treatment for managing chronic conditions. A recent study from the Washington State
Office of Financial Management reports that the uninsured rate for whites sits at 5.1% but is 9.3%
for Blacks, 14.8% for Native Americans and Alaska Natives, and 23% for all other races. When broken
down by Hispanic origin, persons of Hispanic origin report a 17.7% uninsured rate, while non-
Hispanics report a 4.5% uninsured rate.17

• Inadequate knowledge. The health care system is complex, making it difficult for people to
understand and exercise their options to access care. This challenge is exacerbated if the patient is
an immigrant whose primary language is not English. Researchers have documented that Washington
state households whose primary language is not English reported lower rates of preventive care,
fewer checkups, and greater inability to manage medical conditions than households where English is
the primary language.18

• Lack of trust. Mistrust of the health care system is a major challenge among BIPOC communities. In
the African American community, historical injustices have fueled distrust that has lasted more than
a century, contributing to low participation in clinical trials and beliefs that physicians expose them
to unnecessary risks.19 Hispanics have also indicated that anti-immigrant messaging erodes trust,
regardless of citizenship status.20

• Inadequate transportation. In a recent HCA report, a lack of resources to facilitate transportation to

and from appointments was cited as a major factor impeding access to care.15 It was also documented
that patients who were unable to secure transportation often delayed or avoided care altogether. A
2017 study reported that 5.8 million patients in the U.S. delayed medical care because they could not
access transportation, with Hispanics, persons living under the poverty level, and Medicaid recipients
disproportionately harmed.21 Other studies have highlighted that Blacks and Native Americans
were more likely to cite transportation inadequacy as a barrier to access medical care compared to
whites.22,23

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Strategies to Reduce Barriers to Access Health Care Services

Several efforts in various stages of development are focused
on overcoming access barriers that contribute to health and
health care disparities that disproportionately affect BIPOC
and immigrant communities.
• Geography. The state legislature has enacted programs
to reduce geographic barriers, especially since primary
care professionals are disproportionately concentrated in
urban and affluent areas. In recent years, the legislature
altered regulations and provided funding to facilitate the
creation of a new medical school in eastern Washington
and additional residency slots to increase physician supply
across the state.24 The legislature has also allocated
additional funds to expand both the state-funded Health
Professional Loan Repayment Program, which facilitates
the recruitment of providers to rural and underserved areas, and
the Medical Home model, which enhances primary care access.

• Health insurance and financial maldistribution. Washington

state has four decades of experience enacting state-initiated
insurance expansions to address disparities in coverage
and the burden of rising prices for medical services among
socioeconomically vulnerable households.25 With the passage
of the most recent health legislation (Senate Bill 5526), the
Washington Benefit Exchange, the HCA, and the Office of the
Insurance Commissioner have been working together to introduce
Cascade Care and public option plans into the health insurance
exchange. This law intends to improve the quality and affordability
of care by ensuring plans are available for every resident
regardless of income, geography, age, gender, or disability. It also
seeks to reduce financial maldistribution by raising the average
reimbursement rates of public option plans to 160% of Medicare
reimbursement rates. According to a report released by the HCA’s
Universal Health Care Work Group, of the three proposed models
for moving toward universal insurance coverage, two explicitly
describe approaches to cover immigrants presently ineligible
to purchase insurance on health insurance exchanges, while
the third examines the use of state-based subsidies to further
improve affordability of insurance plans.26

• Affordability. Follow-up health reform legislation passed in 2020

also led to the establishment of a health care cost transparency
board whose purpose is to measure the state’s total health care
expenditures, identify cost drivers in the health care system,
and create benchmarks for health care cost growth as a strategy
to reduce cost growth in the state. The board convened its
first meetings in February 2021 and will report annually to the
state legislature with a set of recommendations on how to curb
cost growth. The goal is to help control high and rising health
care costs, which represent a significant access barrier for
socioeconomically vulnerable households.
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• Racial bias and trust. Since 2006, the Governor’s Interagency

Council on Health Disparities (ICHD) has worked to promote equity Over the coming
for all historically marginalized groups, with a focus on addressing
racism. The Council actively advises both the Governor’s Office and months and years,
state legislature on ways to create more equitable public systems. state decision makers
In recent years, the legislature authorized the establishment of the
Office of Equity, whose goal is to address opportunity gaps and will make crucial
health disparities. The ICHD and Office of Equity are dedicated to
advancing an equity, diversity, inclusion, and anti-racism context for decisions about
all executive and legislative decisions. Through the establishment
of the Office of Equity, the state also hopes to rebuild trust among
where to invest funds
Washington state’s BIPOC and immigrant communities and ensure and what aspects
the delivery of culturally competent social services.
of the health care
• Unaddressed burdens. Little has been done legislatively to
address accessibility challenges when scheduling medical care; marketplace to
however, a recent Purchaser Primary Care Support Letter written
to the Washington State Health Care Authority called on primary
regulate.
care providers to offer convenient and flexible care options using
multiple modes of care (e.g., telephone, video, email, electronic
messaging) and extended clinic hours.27 The same letter also
called on providers to offer team-based, continuous, and culturally
sensitive care to ensure that equitable access and delivery of
care is made available to all Washingtonians seeking care. No
consensus yet exists in Washington state on how to reduce financial
maldistribution (typically by increasing Medicaid fee-for-service
reimbursement rates) or expand provider networks (past efforts
sought to moderate through Any Willing Provider and Freedom
of Choice laws). Furthermore, although some existing programs
seek to improve patient knowledge and address transportation
challenges when seeking medical care, such programs are not
standardized or deployed universally across communities.

The Path Forward

Over the coming months and years, state decision makers will make crucial choices about where to invest
funds and which aspects of the health care marketplace to regulate as we transition from the pandemic to
a post-pandemic recovery period. These decisions could benefit from academic-government partnerships
that examine the equity and disparity impacts of current and proposed regulatory, fiscal, and program
policies. Washington state has a history of collaboration with University of Washington researchers, and
the researchers in the Center for Health Innovation & Policy Science (CHIPS)—a policy center focused on
improving equitable health care access across the community and lifespan—are positioned to support
state agencies and the newly established Office of Equity with evidence-based health policy research
that will help advance the state’s mission of equitable and anti-racist access to health care services. This
policy brief, the first of a new CHIPS policy brief series centered on equity as well as economic and health
disparities, is a first step toward building such a partnership.

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