Disparities in healthcare access between rural and urban Maryland residents

Health Care Disparity in Maryland
Context of the Problem
Unsettling Disparities Occur
Approximately 1,600,000 individuals who live in Maryland either do not have access to healthcare as they cannot afford insurance and/or are underinsured.

In "Health care reform: a vital issue for Maryland's nurses," Anne S. Kasper and Leni Preston (2008) stress this unsettling fact, as they point out that Maryland ranks number 24 in the United States in the number of uninsured residents. Fifteen percent of Maryland's population, almost 800,000 people, in fact, is not insured. The significance of the fact relating to those who do not have access to healthcare, Kasper, and Preston (2008) assert, increases as this magnificent number of individuals without access to healthcare does not just adversely affect these individuals. This disparity in access to healthcare also significantly affects other individuals, not just Maryland residents. In response to this significant concern, this qualitative, exploratory study analyzes the disparity in access to health care services between rural and urban residences in Maryland and explores the impact of the lack of financial resources relating to this concern.

In rural areas, residents report a lower median household income with higher unemployment than the average family in the State. The discrepancy may evolve from "lower rural educational attainment, less competition for workers, and limited availability of highly skilled jobs" (Jenkins et al., 2007, p.10)

Since 2004, the median household income in Maryland totaled more than $60,000 annually. The average median household income reported in federally designated rural jurisdictions, however during this same time, equaled 30% less than the statewide average, and in state-designated rural jurisdictions equaled 14% less. In addition, the annual average unemployment rate in Maryland totaled 4.3% less than the 5.5% national average.

Access to Healthcare

The State of Maryland notes the following in regard to access to healthcare:

Access to healthcare refers to "the degree to which people are able to obtain care from the healthcare system in a timely manner" the study of barriers in access often differentiates financial and non-financial barriers and describes the extent to which individuals have a regular source of care. Financial barriers included whether or not an individual has insurance while nonfinancial barriers may refer to transportation, clinic hours and location of healthcare facilities. Having a regular source of care facilitates access to healthcare services and increases the likelihood of interacting with healthcare providers. In addition, having a regular source of care provides the entry point into the complex healthcare delivery system, particularly when specialty care is needed. (Maryland Plan to Eliminate..., 2006, p. 27)

Maryland reports a major shortage in the number of physicians in the State. In fact, the State has 16% fewer physicians available for clinical practice than the national average. The shortages are acute in three regions of the state:

Eastern Shore,

Southern Maryland, and Western Maryland. (Cowdry, 2004, p.4)

Experts project these reported shortages to increasingly worsen over the next seven years. If Maryland does not actively counter these shortages, consumers will experience even more problems gaining access to care and have to wait longer for treatment by a physician. Wait times to see a physician will also increase. More people will also rely more on currently crowded emergency rooms for health care. Maryland needs: "A combination of short, intermediate, and long-term strategies is needed to comprehensively address both primary and specialty care shortages across Maryland. Enhancing reimbursement is absolutely fundamental/critical/essential to the effort" (Cowdry, 2004, p.4). In addition to concerns, Maryland physicians' reimbursement from commercial carriers currently ranks at the bottom 25% of the states. Medical liability insurance and other expenses physicians incur also contribute to problems for physicians to consider practicing in one of the highest cost of living states in the U.S. Two insurers in the Maryland market, also contribute to concerns, as they reportedly reflect "take it or leave it" attitude in contract negotiations. Cowdy also notes;

The State of Maryland must enact designated incentive programs to attract physicians to practice in shortage areas within the state of Maryland, such as; Loan forgiveness programs for Physicians who will commit to providing health care for a minimum of five years in the designated shortage areas. This should be in combination with existing federal programs. Physician credentialing should be by public policy established as a statewide standard in law and be maintained by the Board of Physicians. These standards should be accepted by all licensed providers, insurance carriers and hospitals in Maryland. This credentialing can be based on national standards and adopted statewide. All licensed physicians should be able to have admitting and treatment privileges at the closest hospital to their private offices if they are working within a shortage region within the state of Maryland. (Cowdry, 2008 P.46)

Significance of the Research Maryland Health Care Maryland's inefficient, yet exceptionally expensive healthcare system costs others who live in Maryland, as well as individuals who live outside the state. Currently, the United States (U.S.) "spends more than twice as much per capita as countries that provide health care for all their citizens" (Kasper & Preston, 2008, ¶ 1).

The U.S., however, also stands out as the only industrialized country in the world without a universal health care system. The lack of a universal health care system that would allocate access to health care to all individuals, albeit, does not constitute the focus for this study. Instead, in light of the unsettling, significant statistics relating to the1,600,000 uninsured and underinsured individuals living in Maryland, this study examines the disparity in access to health care services between rural and urban residence in Maryland. This study also explores ways the lack of financial resources impacts Maryland's health care system. Bob Burdon, (2006), president and chief executive officer of the Annapolis and Anne Arundel County Chamber of Commerce, contends that in regard to costs and access to healthcare, "Maryland, like other states in the nation, is at a crossroad..." (¶ 1). The crossroad for Maryland, according to Burdon, constitutes decisions regarding how to gain control of health care costs. Maryland will have to choose whether to adopt a single-payer system or a market-based approach to counter these costs contributing to the reported blatant discrepancies in the health care system. The current paradigm Maryland utilizes to provide health care coverage to its citizens, and contemporary attempts to control health care costs Burdon (2006) contends, mirrors a flawed system. To remedy the system, either the single-payer system or a market-based approach, Burdon (2006) asserts, will eventually work to control care costs. The method to achieve the desired goal, however, significantly varies between the two choices. Burdon (2006) purports, albeit, that the practice of medicine needs to be put back into the hands of doctors and their patients. In addition, different alternatives for treating illnesses, as well as preventive care, need to be developed and implemented.

1.2 Study Area

During the study, the researcher examines the following areas:

The financial impact on access to health care in rural vs. urban areas in Maryland in terms of mortality rate.

The financial impact on access to health care in rural vs. urban areas in Maryland in terms of morbidity rate.

The differences in the impact of cost on access to health care in rural vs. urban areas in Maryland in terms of the ethnic makeup of the populations served. This study, as noted earlier, purports to analyze the disparity in access to health care services between rural and urban residence in Maryland, and explore the impact of the lack of financial resources relating to this concern. To answer the primary research question: What factors contribute to the current disparity in access to health care services between rural and urban residence in Maryland, and also attribute to the ensuing impact of the lack of financial resources? The researcher addresses this research problem in the directed research project by addressing the following sub-research questions.

Sub-Research Questions:

What is the financial impact on access to health care in rural vs. urban areas in Maryland in terms of mortality rate?

What is the financial impact on access to health care in rural vs. urban areas in Maryland in terms of morbidity rate?

What are the differences in the impact of cost on access to health care in rural vs. urban areas in Maryland in terms of the ethnic makeup of the populations served?

Study Hypothesis the research questions crafted for this study contributed to the determination of this study's hypothesis: If the challenges currently attributing to disparities in access to health care services between rural and urban residence in Maryland are effectively addressed and positive changes implemented to counter these disparities, then the disparities, along with the impact of the lack of financial resources relating to this concerns will begin to dissipate and/or decrease.

Figure 1 portrays the state of Maryland, the location for the focus of this DRP.

Figure 1: Map of Maryland, the State (Google Maps, 2009)

1.3 Study Structure

Organization of the Study

The following five chapters constitute the body of Chapter I: Introduction

Chapter II: Review of the Literature

Chapter III: Methods and Results

Chapter IV: Chapter V: Conclusions, Recommendations, and Implications

Chapter I: Introduction

During Chapter I, the researcher presents this study's focus, as it relates to the background of the study's focus, the area of study, the four research questions, the significance of the study, and the research methodology the researcher utilized to complete this study.

Chapter II: Review of the Literature in Chapter II, the researcher explores information accessed from researched Web sites; articles; books; newspaper excerpts; etc., relevant to considerations of the disparity in access to health care services between rural and urban residence in Maryland and the impact of the lack of financial resources. The researcher initially accessed and reviewed more than 35 credible sources to narrow down the ones noted in the reference section in this study. The literature review chapter presents a sampling of literature to support the research questions this study addresses.

Chapter III: Methods and Results Throughout Chapter III, the researcher proffers information utilized to address contemporary concerns/challenges/consequences relating to determining the information used in this investigation. This chapter also presents the overall methods and techniques the researcher implemented to conduct this study. Considerations for the methodology chapter include data/information the researcher uses; identifying it as primary and/or secondary. In addition, the researcher notes the data compilation process during this section and advises of any known or anticipated sources of error in the data/information. As the topic of the disparity in access to health care services between rural and urban residence in Maryland and the impact of the lack of financial resources has not been thoroughly investigated by previous researchers, the researcher uses his study effort to primarily serve as an exploratory study (Potter, 2002). The distinctive dearth or previous research on the issue enveloping this study's focus points to a qualitative research methodology being most appropriate (Potter, 2002).

Also in Chapter III, the researcher examines the information retrieved/reviewed/related for this study, and in turn, dissects and features results relevant to the disparity in access to health care services between rural and urban residence in Maryland and the impact of the lack of financial resources. The researcher notes the study's most relevant findings in this chapter.

The researcher adapts, creates, and presents a variety of tables and graphs to depict particular, vital noteworthy information/data from the collection of documents reviewed in the literature review chapter. The analysis of information the researcher retrieved from the documented available evidence contributes to the results the researcher draws from the research to answer the research questions (Pope et al., 2000).

Chapter IV: Summary and Conclusions

During Chapter IV, in the discussion section, the researcher recounts the study scenario and further expounds on the findings from the retrieved information and analysis chapter. In the conclusion section, the researcher confirms that this study's research questions were appropriately addressed and relates to the determination of the study's hypothesis. Ultimately, based on this study's findings, the researcher proffers recommendations for future researchers to ponder for potential, future study projects. The researcher also notes any lessons, in hindsight that this study's efforts recovered.

Aims and Objectives

The researcher's primary aim for this study is to examine the disparity in access to health care services between rural and urban residence in Maryland and the impact of the lack of financial resources.

Study Hypothesis the research questions crafted for this study contributed to the determination of this study's hypothesis: If the challenges currently attributing to disparities in access to health care services between rural and urban residence in Maryland are effectively addressed and positive changes implemented to counter these disparities, then the disparities, along with the impact of the lack of financial resources relating to this concerns will begin to dissipate and/or decrease.

Objective

Conduct a thorough Literature Review of relevant information relating to the disparity in access to health care services between rural and urban residence in Maryland and the impact of the lack of financial resources.

Objective

Identify the characteristics components relating to the financial impact on access to health care in rural vs. urban areas in Maryland in terms of mortality rate.

Objective

Examine and note data relating to the financial impact on access to health care in rural vs. urban areas in Maryland in terms of morbidity rate.

Objective

Determine the number of differences in the impact of cost on access to health care in rural vs. urban areas in Maryland in terms of the ethnic makeup of the populations served.

During the next chapter of this study, the researcher completes the normal retrieval and maintenance of relevant literature not only relating to the approximately 1,600,000 individuals who live in Maryland either do not have access to healthcare as they cannot afford insurance and/or are underinsured, but also to those who do have access. In the end, the researcher notes, as Kasper and Leni Preston (2008) stress, the disparities that occur reach across communities and groups and touch individuals within, as well as outside the State of Maryland.

CHAPTER II

LITERATURE REVIEW

Access to health care, defined by the Institute of Medicine as 'the timely use of personal health services to achieve the best possible health outcomes,' is a national, state and local problem" (Healthy Maryland Project 2010, 2001, p. 12).

2.1: Introduction

This study's literature review, in a figurative sense, depicts a number of similarities, along with numerous disparities, in the literature examining one particular facet of a particular subject of health care disparity in Maryland. In addition, this study proposes to achieve the best possible outcomes with regard to the researcher's retrieval of information/data.

The timely use of the researcher's efforts in implementing an orderly, organized review helps ensure that the investment of the researcher's time will evolve into a healthy, well-developed effort that proves to be a success. The following steps prove to be pertinent in the process of conducting the Literature Review.

1. Identifying the research topic:

Disparities in Maryland Health Care

2. Reviewing secondary source and examining articles or decade reviews; e.g. accessing contemporary research, including journal articles; book; magazines; news releases. The researcher utilized primary Websites, particularly those officially sponsored by the State of Maryland.

3. Developing and personalizing an effective way to implement the search strategy

4. Conducting searches; utilizing key terms. Key terms the researcher utilized to conduct searches throughout this study's literature review included; however, were not limited to:

Maryland Health Care

Disparities in Maryland Health Care

Health Care

Disparity

Mortality

Mortality rate

Morbidity

Limited access, Healthcare, Maryland

Financial strain, Healthcare, Maryland

Financial Impact, Access, Healthcare

Healthcare Maryland, Rural vs. Urban

Disparity Access, Healthcare

Disparity, Healthcare, Ethnic Groups

Impact Cost, Healthcare

Literature Reviews, per se Literature Reviews (2007) advises that literature reviewed in a study may not necessarily consist of the great literary texts of the world. They may range from numerous government pamphlets to scholarly articles to any collection of materials on a topic. As comprehensive knowledge of the literature of the field proves vital to most research papers, the literature review, as in this study albeit, provides a solid background for study's exploration. A review does not necessarily mean the researcher will present his/her personal opinion regarding whether he/she liked these sources or what, if anything, he/she liked about them. Instead, the literature review relates information from published/credible sources focusing on/in a particular subject area. Sometimes the information is constrained to "a particular subject area within a certain time period" (Literature Reviews, 2007, What is a literature... section, ¶ 1).

The reviews additionally serve as useful reports to help the professional, and the scholar stay abreast of current information in his/her field. The literature review traditionally possess an organizational pattern and combines both summary and synthesis. it, nevertheless, may review or simply summarize sources. During the review of literature, the researcher summarizes and recaps relevant information from sources. During the process, the researcher synthesizes information, a process which consists of reshuffling and/or re-organizing relevant researched information. The researcher may ultimately present a fresh interpretation of old material, or he/she may link fresh material with older interpretations. A literature review may also sketch the intellectual progression of the field in/of focus, and include major debates/issues. Sometimes, during the literature review, the researcher evaluates the researched sources and, in turn, recommends the most relevant or pertinent information to the reader (Literature Reviews, 2007). An academic research paper basically supports the researcher's own argument while the literature review aims to summarize and synthesize the arguments and ideas other researchers relate. As the literature review emphasizes the argument, the academic research paper embraces a variety of sources. Traditionally, however, it only consists of a select, predetermined number of sources. A literature review, albeit, may also propose an "argument," however, relating an argument in the literature review is not vital as exploring a number of sources. Generally, an academic research paper, as well as, the literature review encompasses numerous identical and/or similar elements.

This study, as numerous other academic research papers, contains a literature review section. In each instance, the researcher emphasis may be on the argument or the sources. For this study, the research focuses on the "argument" regarding the disparity in access to health care services between rural and urban residence in Maryland and the impact of the lack of financial resources Before one begins his/her review of the literature, the researcher must ensure he/she is clear regarding the following points:

The approximate/required number of sources to include in the review. For this study, the researcher determined to utilize between 15-25 sources.

The types of sources: Credible Web sites; books; journal articles; magazine articles / interviews; newspapers; brochures; etc.. The researcher used a variety of credible Web sites; books; journal articles; magazine articles / interviews; newspapers; brochures; etc. during the literature review process.

If the researcher will summarize the sources; synthesize, or critique the sources by discussing a common theme or issue. During this literature review, the researcher summarizes and synthesizes a number of sources. The researcher, however, does not critique the researched information.

Whether the researcher evaluate the sources. The researcher mentally evaluates the sources to confirm they are credible, however does not critique the researched information during the review, nor in the body of the study, as sources were all credible.

If any subheadings and/or other background information will be included.

Whether definitions and/or a history be part of the literature review. Subheadings, along with other background information are included in the literature review. Definitions and a bit of history relating to this study's focus also constitute part of the literature review.

Before the Start

Prior to the start of the process, the researcher may benefit from searching/examining other literature reviews in the discipline or in his/her focus/interest or read several examples to obtain a sense of similar themes he/she may want to search for in his/her research. A review of other reviews may also give the researcher ideas regarding ways to organize his/her final review.

To find these examples, the researcher may simply type his/her topic/terms along with the word "review" in his/her search engine to discover articles of this type on the Web. In the reference / bibliography section of sources may also proffer entry points into the researcher's exploratory process. For this study, the researcher did note several examples of other reviews, prior to conducting the literature for this DRP. During the research process for this study's literature review, the researcher also noted the following points:

Narrowing the topic nets more relevant results.

Confirming sources are current proves vital.

The researcher needs to develop strategies for writing the literature review

He/she need to find a focus and develop a list of key words/phrases.

He/she needs to create a working hypothesis, along with applicable, appropriate research questions.

He/she needs to determine how to best organize the massive amount of information that must be reviewed.

Covering the basic categories constitutes the initial step.

Organizing the body proves to be the next step.

The organization may be:

Chronological

Methodological

Thematic

Following the choice of the organizational method for the body of the review, the researcher will then be ready to begin researching information to utilize in his/her study. Sections usually arise naturally from the researcher's organizational strategy.

In a chronological review, the researcher would delegate a subsection for each vital time period. In a thematic review, the researcher would craft subtopics based on the factors relating to the theme or issue. At times, however, the researcher may need to add additional sections that prove vital necessary to/for the study, yet theses may not fit in the body's organizational strategy. Even though the researcher makes the final choices as to what sections to include in the literature review, he/she needs to only include what is necessary for his/her study. The following list depicts a fnumber of other sections the researcher may consider.

Contemporary Situation: Information vital to understand the literature review's focus/topic.

History: The field's chronological progression; the literature, or if the body of the literature review is not a chronology, an perception needed to understand the literature review.

Methods and/or Standards: The criteria the researcher utilized to choose the sources in his/her literature review or the way in which he/she presents the researched information. The researcher may explain, for instance, that his/her review includes only particular type publications.

Questions for Further Research:

What questions did the review stimulate, relating to the field? As a result of the review, how will the researcher further his/her research?

As the researcher summarizes and synthesizes the ideas of others within paragraphs in the review, as well as throughout the review, he/she must retain his/her own voice (as the writer/researcher).

The researcher's voice for this study aims to mirror.... (customer to determine this and add)

This study presents the reviewed literature in a thematic organization, with the themes covered relating to disparity in Maryland's health care including:

Financial Impacts Mortality Rate

Disparity Financial Impacts Morbidity Rate

Disparity Differences in Cost Impact

Financial Impacts on Mortality Rate

During this section, the researcher relates information regarding the financial impact on access to health care in rural vs. urban areas in Maryland in terms of mortality rate.

Mortality fatal outcome or, in one word, death. The word "mortality" is derived from "mortal" which came from the Latin "mors" (death). The opposite of mortality is, of course, immortality. (Mortality, 2002)

Rural Communities throughout Maryland

Rural communities throughout Maryland, which differ in population density, represent approximately 30% of Maryland's population and nearly 80% of the State's land area. The rural area's remoteness from urban areas, along with its economic and social characteristic are reportedly growing in population. They are also becoming popular destinations for retirees and others willing to commute to the extended distance to/from work.

The challenges to providing quality health care services and delivery to rural Maryland largely result from their geographic isolation and lack of the critical population mass necessary to sustain a variety of primary and specialty services. (Jenkins et al., 2007, p.1)

Efforts to address health care disparities in rural areas are often made difficult by struggling economies and limited financial and human resources. Compared with the State overall, Maryland's rural communities tend to have fewer healthcare organizations and professionals, higher rates of chronic disease and mortality, and larger Medicare and Medicaid populations. Evidence indicates that rural populations fare worse in many health and economic indicators, and do not receive the same quality, effective, and equitable care as their suburban counterparts. Rural populations tend to be older and exhibit poorer health behaviors such as higher rates of smoking and obesity, relative to the State, although there is variability in health behaviors among rural communities. A growing portion of the rural population suffers from chronic diseases. The costs for the State to care for this population will increase over the next few decades unless attention and funding are directed toward improvements in preventive health. (Jenkins et al., 2007, p.1)

The rural health system could improve residents' quality of life more effectively if access to health care providers, prescription medications, and health education improved. Unless action is taken now, the future burden of chronic disease in many rural communities could become enormous. The need for improvement in rural health has also been documented in the Institute of Medicine's,"Quality through Collaboration: The Future of Rural Health Care."According

The Future of Rural Health Care."According to this publication,"rural communities have been on the periphery of discussions of national health care quality. (Jenkins et al., 2007 p.1)

In response to the pressing health needs in Maryland's rural areas, the State of Maryland has developed a plan to overhaul healthcare in rural areas.

The Office of Rural Health convened a Steering Committee to create the Maryland Rural Health Plan. The Plan provides information on existing resources, identifies gaps in services, identifies barriers that limit access to care, and provides recommendations for improving the delivery of health care to rural residents. The strategies and activities in this Plan are expected to reduce chronic disease and empower individuals to take responsibility for their health.

The Steering Committee assumed the tasks of:

Assessing health status in Maryland's rural areas;

Examining the accessibility and affordability of health care in rural areas; and Identifying the most pressing health issues, and developing strategies and activities to address those health issues. (Jenkins et al., 2007, p. 2)

The Steering Committee identified the following priority areas for health in rural

Maryland:

Access to primary and specialty care and to pharmacy services;

Access to oral health;

Behavioral health (mental health and substance abuse); and Improvement in behaviors leading to a healthier lifestyle. (Jenkins et al., 2007, p.2)

Addressing the Rural Health Challenges

To address the health challenges in Maryland's rural communities, the Steering Committee developed the following three strategies:

Recruit and retain health care providers -- including primary care, behavioral, and oral health professionals -- in rural areas;

Support increased access to pharmaceuticals for the low-income, rural population; and Establish comprehensive, preventive health clinics in underserved, rural areas. (Jenkins et al., 2007, p. 2)

Maryland's plan presents in regard to improving access to health care purports a long-term perspective, and its success will be measured by improved health care services and outcomes in rural areas. Evaluating progress in achieving the Plan's recommendations, especially over the longterm, will be important for making any needed adjustments and for learning from achievements and failures. In order to ensure the success of the Plan, local health departments in rural jurisdictions, rural health groups, academic institutions, professional organizations, and foundations will all have to be involved. By identifying areas where additional attention is needed, the Plan serves as a guide to all organizations in the State. No single organization can carry out these activities alone. Rather, these goals and strategies are listed as a call to action to encourage any organization involved in rural health to address one or more of the identified priorities. (Jenkins et al., 2007, p. 2) There is no universally accepted definition of rural; rather, there are many classification systems in use by a variety of federal and state programs. Although there is no single definition, rural jurisdictions share common characteristics that set them apart from their suburban and urban counterparts, such as geographic isolation, transportation barriers, and limited access to and availability of health care. Rural areas can also be differentiated by their common health and economic challenges. Rural Healthy People 2010 identified the top ten rural health priorities in order to identify focus areas of particular significance to rural America. In rank order, with one being the top priority, these are:

Access to quality health services

Heart disease and stroke

Diabetes mellitus

Mental health and mental disorders

Oral health

Tobacco use

Substance abuse

Maternal, infant

Child health. (Jenkins et al., 2007, p.7)

Limited availability of primary care providers, specialists, and health care services is a barrier to accessing and obtaining necessary medical care, even for those with insurance. Citing low reimbursement rates, many providers do not accept Medicaid nor offer a sliding-fee scale, further limiting the number of accessible providers in rural areas. The rural population often must drive greater distances to receive specialty care, such as dialysis. There are 34% fewer primary care providers per 100,000 population in the state designated rural jurisdictions than the State overall and 28.7% fewer primary care providers in federally-designated rural jurisdictions. The total number of physicians, including specialists and primary care physicians per 100,000 population, is 24.8% lower in the state-designated rural jurisdictions than the State. (Jenkins et al., 2007, p. 15)

Another indicator commonly used to gauge access to primary care is hospitalizations for ambulatory-care sensitive conditions, when good outpatient care can prevent hospitalization, or when early intervention can prevent complications or more severe disease. Hospitalizations for these conditions may indicate a lack of accessible and quality primary care in a community. Diabetes is an example of an ambulatory-care sensitive condition for which Maryland data is available by jurisdiction. (Jenkins et al., 2007, p. 16)

Mortality rates for all causes of death, diseases of the heart, and malignant neoplasms are higher in state- and federally-designated rural jurisdictions than the State. Mortality due to diseases of the heart is especially high in Dorchester, Garrett, and Somerset counties, while deaths from malignant neoplasms, or cancer, are highest in Kent and Worcester counties. (Jenkins et al., 2007, p. 24)

There are several ways to measure health care access, including health insurance coverage, assessments by patients of how easy it is to gain access to health care, having a usual source of care, and the receipt of care. For most of these measures, according to the Behavioral Risk Factor Surveillance Survey, Maryland's rural population experiences greater barriers to accessing care.Although Maryland's rural population often has a usual source of care to the same extent as the State population overall, they often experience lower rates of health insurance and poorer health outcomes, suggesting they are not receiving the services they need in a timely manner. (Jenkins et al., 2007, p. 26)

Affordability is closely linked with access, as lack of health insurance bars many from needed health care. Limited health insurance and out-of-pocket expenses make it especially difficult for the rural population to afford the preventive and primary care they need.

Prohibitively expensive co-pays and high deductibles may prevent residents with health insurance from being able to afford health care visits. Problems of higher unemployment and lower income in rural areas of Maryland exacerbate the affordability problem. (Jenkins et al., 2007, p. 26)

The Agency for Healthcare Research and Quality defines preventive care and health promotion "as those situations in which consumers may consider themselves healthy or physically at risk but have not yet been labeled with a diagnosis."17 the Center for Preventive Health Services in Maryland's Department of Health and Mental Hygiene has the mission "to promote health and the quality of life by preventing and controlling chronic diseases, injury, and disability."The Center administers the Preventive Health and Health Services Block Grant funds.These funds are provided to local health departments in each of Maryland's jurisdictions to develop and implement interventions that are best suited for their communities. Funds are being used for services and education on a range of health issues, including heart disease, stroke, osteoporosis, hypertension, and diabetes. (Jenkins et al., 2007, p. 26)

Financial Impacts on Morbidity Rate

This section considers the financial impact on access to health care in rural vs. urban areas in Maryland in terms of morbidity rate.

Definition of Morbidity

Morbidity is an incidence of ill health. It is measured in various ways, often by the probability that a randomly selected individual in a population at some date and location would become seriously ill in some period of time. (add source)

Only six jurisdictions in Maryland are classified as urban or suburban. Baltimore City constitutes the only urban jurisdiction in Maryland. The five suburban jurisdictions in Maryland include:

Worcester,

Anne Arundel,

Baltimore County,

Howard,

Montgomery and Prince George. (Jenkins et al., 2007, p.7)

The U.S. Census Current Population Survey (CPS) reported that 85.4% of Maryland residents (based on total population estimates) had some type of health care coverage in 2004.6 This is a decrease from 87.6% in 2000.The most recent jurisdiction-level health insurance rates are from 2000 and indicate that people in rural areas have lower rates of health insurance than those living in suburban areas in Maryland. Most Marylanders receive health insurance through employers. However, those employed in rural areas are more likely to work seasonally or for smaller employers who do not provide health insurance as a benefit. State Medicaid does provide health insurance options for low income families who cannot afford coverage privately. Even with this coverage, thousands of Marylanders do not have health insurance. Health insurance is critical to health and financial well-being. (Jenkins et al., 2007, P.14)

The uninsured and under-insured are more likely not to seek treatment until a health problem becomes a serious medical issue. This subset of the population experiences poorer health outcomes and higher mortality rates, and must pay for their care out-of-pocket, placing strain on their finances. Nationally, low-income rural adults with private coverage fare worse in measures of healthcare access than urban low-income adults with private insurance. Medicaid and Medicare enrollments are higher in the federally-designated rural jurisdictions compared to the State. Medicaid enrollment is 27% higher in federally designated rural jurisdictions than the State overall. Medicare beneficiaries make up 12.6% of the population statewide and 13.4% in the state-designated rural jurisdictions.The Medicare beneficiary population is 41% higher in federally designated rural jurisdictions compared to the State. (Jenkins et al., 2007, P.14)

Improving availability of care means ensuring there are enough providers and facilities available to provide sufficient care.The poorer health outcomes and rates of chronic disease in Maryland's rural areas suggest there may not be enough providers or health delivery sites available. Some of the existing programs to increase the health care workforce include loan-assistance repayment programs, J-1 visa waivers, the National Health Service Corps program, and the National Interest Waiver Program. Although there are Federally Qualified Health Centers (FQHCs) and other facilities throughout the State that provide health care to anyone regardless of income, there are rural areas in Maryland without health centers and where existing health centers do not have the capacity to meet the need. (Jenkins et al., 2007, P.25)

The Agency for Healthcare Research and Quality describes access to health care as "the timely use of personal health services to achieve the best health outcomes."15 the 2004 National

Healthcare Disparities Report identified two major barriers to accessing care among rural populations: access to health insurance and the longer distances rural residents face to reach health care delivery sites.16 the AHRQ identifies three steps to attaining access to care:

Gaining entry into the health care system.

Getting access to sites of care where patients can receive needed services.

Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust. (Jenkins et al., 2007, P.25)

There are many causes for Health Care Disparities in Rural and Urban Maryland and many obstacles facing providers and patients. A combination of unique factors that Marylanders face is economic factors, cultural and social differences, education, isolation and job opportunities. (Wasserman, 2007, P. 13)

Rural residents tend to be poorer and more likely to live at the poverty level. On the average, per capita income is $7,417 lower than in urban areas. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty. People who live in rural America rely more heavily on the federal Food Stamp Program. Alcohol abuse and use of smokeless tobacco are significant problems among rural youth. DUI arrests are significantly greater in rural communities. (Wasserman, 2007, P. 14)

The aging populationin Maryland is known as the "Silver Sunami." Fourteen percent of the population in Maryland elderly, on average Maryland residents will live 78 years. The elderly populations are moving from urban areas to rural areas. There is a great need for geriatric trained primary care physicians and in home services. Rural jurisdictions have 40% more elderly citizens than urban populations. The elderly population is projected to grow to 25% by 2030 in rural Maryland. (Wasserman, 2007, P. 24)

The simple life. The open spaces. The quaint towns. The rural attraction. But they come at a cost. Fewer services. Lack of health care. Consolidated schools. No Internet service. Lack of jobs. Low incomes. (Farquhar, 2006, Para. 1)

And as urban areas grow, people who chose the rural life have less representation in the state capitol. Maryland Senator Mac Middleton, for example, is the last full-time farmer left in his legislature. (Farquhar, 2006, Para. 2)

Rural Maryland is losing clout to the urban centers," he says. "Every election a few more delegates came in from Baltimore and suburban counties, and fewer from rural ones." (Farquhar, 2006, Para. 3)

The biggest job of the caucus is teaching the urban legislators about living in rural areas," says Flake. (Farquhar, 2006, Para. 10)

Beyond just promoting agriculture, these caucuses are discussing issues such as the lack of health care and social services, a weakening tax base, water needs, housing costs and economic development -- the major concerns facing rural America. (Farquhar, 2006, Para. 11)

Attracting doctors is also a problem in rural Maryland. Without the facilities and economic base to build a practice, most young physicians remain in the larger cities. Even doctors from rural areas who want to return find it difficult to maintain a practice because many of their clients are on Medicaid, which doesn't always reimburse the full cost of services. (Farquhar, 2006, Para. 19)

Senator Middleton took up the cause. He introduced a bill that places a 2% tax on HMOs, and dedicates the funds to Medicaid reimbursement. It greatly benefited rural areas, he says. NO DIFFERENT in RURAL STATES Even in rural states, rural legislators feel alone. (Farquhar, 2006, Para. 20) new book released today by the W.K. Kellogg Foundation describes a broad range of proven solutions for helping communities better serve the millions of uninsured Americans who lack adequate health and dental care. ("Book more than...," 2002, para. 1)

More than a Market: Making Sense of Health Care Systems" draws on experiences gained from the Foundation's Community Voices: HealthCare for the Underserved initiative. This $58.5 million effort, the largest in the Foundation's 72-year history, supports a cross section of 13 urban, rural, and suburban projects. ("Book more than...," 2002, para. 2)

The book, much like the Community Voices initiative, is based on the premise that our health care system does not work for everyone, especially for those on the margins of society," said William C. Richardson, Kellogg Foundation president and CEO. "Yet what we've done through our 13 model projects is demonstrate that it can work. If we're creative -- and cooperative -- we can provide insurance and safety net services in a way that's affordable and sustainable." ("Book more than...," 2002, para. 3)

Working both individually and as a network, the sites function as learning laboratories where new plans and programs are developed. Participants have included dozens of organizations and health systems, and thousands of community participants who are most effected by the shortage of services. ("Book more than...," 2002, para. 4)

As reported in "More than a Market," Community Voices projects seek to strengthen the safety net for the underserved and improve health services delivery. The programs represent a sample of those now underway: In Baltimore, Maryland, a Men's Health Center provides primary care - physicals for work, illness care, mental health, and other services - to underserved men in the community. ("Book more than...," 2002, para. 6)

Essentially, Community Voices builds on the public will to create new systems and services for those who have been left behind," Richardson said. "Americans have an innate sense of fairness, and there's widespread support for the kinds of reforms and innovations this initiative has helped to bring about." ("Book more than...," 2002, para. 7)

Another key component of the work has been partnerships. Health care delivery and financing are complex, multi-layered issues and no institution can solve these problems alone. Our projects have succeeded by building bridges between local people, health systems, public officials and government agencies." ("Book more than...," 2002, para.11)

More than a Market" tells the story of how people from a range of professional and community backgrounds have come together to share their knowledge and join the rising chorus of voices that's calling for change. ("Book more than...," 2002, para.12)

Community Voices is a six-year initiative that's now at its midpoint and this book details the lessons we've learned thus far," said Henrie Treadwell, Kellogg Foundation program director in health. "We released the book now to engage readers in a national conversation about health, health care systems, and the potential of communities to lead and create change." ("Book more than...," 2002, para.13)

We haven't found any magic potion, but we have made impressive headway. And in a slowing economy, with more people unemployed and uninsured, the solutions outlined in 'More than a Market' are of immediate value to businesses, public institutions, government policy makers, and grantmakers." ("Book more than...," 2002, para.14)

Cancer is one of the leading causes of morbidity in the United States. The Cancer Prevention, Education, Screening and Treatment Program was created under the Cigarette Restitution Fund (CRF) and seeks to reduce death and disability due to cancer in Maryland through implementation of local public health and statewide academic health center initiatives. The mission of the Cancer Prevention, Education, Screening and Treatment Program is to reduce the burden of cancer among Maryland residents through enhancement of cancer surveillance, implementation of community-based programs to prevent and/or detect and treat cancer early, enhancement of cancer research, and translation of cancer research into community-based clinical care. The Cancer Prevention, Education, Screening and Treatment Program envisions a future in which all residents of Maryland can lead healthy, productive lives free from cancer or disability due to cancer. (M00F03.06, 2008, P.1)

KEY GOALS, OBJECTIVES, and PERFORMANCE MEASURES

Goal 1. To reduce overall cancer mortality in Maryland.

By calendar year 2010 reduce overall cancer mortality to a rate of no more than 172.0 per 100,000 persons. (Age-adjusted to the 2000 U.S. standard population.)

Goal 2. To reduce disparities in cancer mortality between ethnic minorities and whites.

By calendar year 2010 reduce disparities in overall cancer mortality between blacks and whites to a rate of no more than 1.08. (Age-adjusted to the 2000 U.S. standard population.) (M00F03.06, 2008, P.1)

Goal 3. To reduce mortality due to each of the targeted cancers under the local public health component of the CRF program.

By calendar year 2010 reduce colorectal cancer mortality to a rate of no more than 15.9 per 100,000 persons in Maryland. (Age-adjusted to the 2000 U.S. standard population.)

By calendar year 2010 reduce breast cancer mortality to a rate of no more than 23.1 per 100,000 persons in Maryland. (Age-adjusted to the 2000 U.S. standard population.)

By calendar year 2010 reduce prostate cancer mortality to a rate of no more than 22.0 per 100,000 persons in Maryland. (Age-adjusted to the 2000 U.S. standard population.)

Goal 4. To increase access to cancer care for uninsured persons in Maryland.

To provide treatment or linkages to treatment for uninsured persons screened for cancer under the Cancer Prevention, Education, Screening and Treatment Program. (M00F03.06, 2008, P.2)

Goal 5. To reduce the burden of cancer and tobacco-related diseases through the Maryland Statewide Health Network (MSHN) by: conducting prevention, education and control activities; promoting increased participation of diverse populations in clinical trials; developing best practice models; coordinating with local hospitals, health care providers and local health departments; and expanding telemedicine linkages. (M00F03.06, 2008, P.3)

Different solutions to creating better health care in rural areas because there are limited specialists, too much area to cover.

With limited specialists, more area to cover, and better reimbursement models, many hospitals are embracing telemedicine. (Lawrence, 2009, Para. 1) fundamental change in the way healthcare is delivered is rapidly gaining ground in the United States. Telehealth (or telemedicine) is connecting patients and providers - or providers and providers - in ways that don't rely on faceto-face contact. In remote or underserved areas, it can be a way to deliver specialty services and education by optimizing the use of available professionals. And even in large urban areas, the rise of e-ICUs and other telehealth specialties like e-pharmacy, e-dermatology and even e-psychiatry makes the sting of specialty shortages less acute. (Lawrence, 2009, Para. 2)

In what many say will be the most far- reaching consequence of this trend, patients, through remote monitoring at home, can begin to take charge of their disease - with chronic conditions managed effectively in a home setting, conserving valuable hospital resources for the most critical cases. With the costs of treating chronic conditions at a staggering 75% of the $2 trillion health expenditure, according to Health Industry Insights, a consulting company based in Framingham, Mass., remote patient monitoring (RPM) technology will be an effective way to address that cost. "There are many drivers that will feed growth in this area," says Marc Holland, research director of the company. Those drivers, he says, are the increasing prevalence of chronic conditions, the aging of baby boomers, the escalating shortages of medical professionals, and the spiraling cost of care. (Lawrence, 2009, Para. 3)

Two legislative acts passed in July of 2008 may also spur growth: the approval of Medicare reimbursement for telemedicine-enabled follow-up inpatient consultations, and the expansion of the list of qualifying sites authorized to bill Medicare for telemedicine services. (Lawrence, 2009, Para. 4)

In addition, millions of dollars in government funding have recently become available to states that will support telemedicine expansion, often through broadband and connectivity initiatives. For example, six hospitals in rural Maryland will implement Baltimore-based Visicu's eICU, thanks to a $3 million grant from CareFirst BlueCross BlueShield (Owings Mill, Md.). And in November, the USDA awarded more than $1.5 million in Rural Utility Service grants to hospitals around the country to fund expansion of e-ICU services to rural communities. (Lawrence, 2009, Para. 5)

Differences in the Cost Impact During the third section of this study's literature review, the researcher examined the differences in the impact of cost on access to health care in rural vs. urban areas in Maryland in terms of the ethnic makeup of the populations Maryland's health care system serves.

The 2006 Maryland Plan to Eliminate Minority Health Disparities is offered as a beginning dialogue on the causes, solutions and challenges faced by the state. This Plan represents a coordinated effort of the public, health professionals, academia, community health groups, interest groups and the Department of Health and Mental Hygiene. (Hussein et al., 2006, p.11) the most important feature of the States plan is the number of public comments; comments were received from over 1,200 citizens. Other reports on minority health in Maryland have been completed; however this plan depicts the first to address minority health disparities. Minority health disparities are noted as differences in the incidence, mortality, and burden of diseases along with other adverse health conditions that exist among the minority groups in the state.

This Plan, the first on the elimination of minority health disparities, is intended to promote dialogue across Maryland on the causes, solutions and challenges faced by the state. The Plan is a consensus-based document. The Office of Minority Health and Health Disparities (MHHD) within the Maryland Department of Health and Mental Hygiene (DHMH) undertook a major effort to obtain input and discussion among a large segment of groups and individuals with a professional or personal concern about health disparities. (Hussein et al., 2006, p.13) This particular plan, built on past Maryland minority health initiatives differs from past plans as it provides a framework for developing steps to eliminate minority health disparities.

In order to assess the disparities in health in Maryland, it is necessary to look at health outcomes, care and treatment, and the supporting system; therefore, for this report disparity is defined in the context of burden and care. A health disparity can be defined as a difference in the burden of illness, injury, disability, or mortality between one population group and another [2]. A healthcare disparity can be defined as differences in insurance coverage, access to or quality of healthcare services [2]. The causes of these disparities are myriad and complex, and may emerge from any number and combination of patient, healthcare system, and societal factors. This first Maryland Plan to Eliminate Minority Health Disparities addresses both types of disparities. (Hussein et al., 2006, p.13)

First, there is a fundamental principle that all of our nation's citizens have a human right to healthcare of equally high quality regardless of racial or ethnic background (Hussein et al., 2006, p.13).

If Maryland fails to act, it puts the entire state at risk, therefore the State must correct the imbalance in health. Racial and ethnic minority groups comprise a larger proportion of the national and state population. The future health of Maryland in the coming years will be influenced by its success in improving the health of ethnic groups. The foundation for success in Maryland schools, employees, and businesses, can be accomplished by a positive health status in Maryland. The elimination of minority disparities in health and healthcare will have a personal and economic benefit for the individual citizen of this state. Health disparities have a negative economic and social impact. For the groups affected, health disparities result in premature death, disability, disease, and a diminished quality of life. Economically, the diminished health status that is often the result of healthcare disparities jeopardizes productivity and viability in the workplace. This Plan is the foundation of research that will expand our understanding of the economic implications of racial and ethnic health disparities in the state. (Hussein et al., 2006, p.13)

Improvement in health care access is possible, and in fact some findings reassure and demonstrate that targeted efforts significantly reduce disparities. The National Healthcare Disparities Report highlights targeted activities that are associated with reductions in disparities of both health status and healthcare. An example of Maryland's success reducing the cancer mortality disparity is presented in the Health Disparities in Maryland section of this Plan. (Hussein et al., 2006, p.14) This report significantly contributes to the public discourse on minority health and healthcare delivery by presenting a statewide overview of health disparities related to race, ethnicity, gender, and jurisdiction in Maryland. Although, this report is not designed to measure the progress of any one program or policy, the data and information presented provide suggestions for performance measures to monitor the state's progress toward optimal health for all its citizens. (Hussein et al., 2006, p.14)

Finally, legislators in Maryland have recognized the significance of the impact of health disparities on the citizens of Maryland, and passed House Bill 883 (in 2003) and House Bill 86/Senate Bill 177 (in 2004) which have directed the department to develop and implement a Plan to reduce health status and healthcare disparities based on gender, race, and ethnicity. (Hussein et al., 2006, p.14)

The purpose of this Plan is to provide information to assist Maryland's communities in planning and implementing ways to reduce minority health disparities. This purpose will be met through the following objectives:

To document health and healthcare disparities in Maryland by race, ethnicity, and gender. This report examines the burden of illness and death as well as the quality of healthcare for minority and majority residents of Maryland.

Present information that should assist policymakers and researchers in their attempts to determine focus areas in disparity, monitor trends, and to identify successes in reducing disparities.

Identify areas for improvement in data collection that should suggest the need for systematic collection and analyses of health and healthcare data by racial/ethnic groups, including important subgroups. Complete and accurate data is essential for targeting efforts to eliminate health disparities.

Provide baseline data from which others may be able to measure the state's initiatives to reduce health and healthcare disparities.(Hussein et al., 2006, p.14)

In this Plan minority is defined as members of the following groups: African-American, American Indian, Hispanic, and Asian/Pacific Islander. This definition of minority groups is based on House Bill 86, from the 2004 Maryland Legislative session [10]. In addition, this Plan recognizes that health disparities extend beyond racial and ethnic definitions alone. Groups that have faced discrimination because of underlying differences in social status can also lead to disparities in health and healthcare [11]. These groups are considered "vulnerable populations" and include individuals with stigmatizing health conditions such as mental illness, recent immigrants and refugees, women and men, and incarcerated populations [11]. Most of the statistics collected are based on standard Office of Management and Budget (OMB) categories. OMB makes a distinction between race and ethnicity. The term "race" is an inexact socio-biological category, but commonly accepted; "ethnicity" is used to describe groups with a common cultural or language heritage but can, as in the case of Hispanics and Asians, mask significant differences by country or culture of origin. Where possible, an effort has been made to report figures for Non-Hispanic White and Non-Hispanic African-Americans in order to separate race from ethnicity. OMB uses the term "Black" rather than "African-American," and distinguishes between Hispanic and Non-Hispanic White and Black populations. In this document, however, the term "African-American" is used. (Hussein et al., 2006, p.14)

Efforts to improve the health of the nation will undoubtedly be influenced by important changes in demographics [12]. The United States population has become progressively more diverse due to recent increases in Hispanic and Asian populations. Currently, one in three Americans are either foreign born or members of ethnic/racial minority groups. If this trend continues, racial and ethnic minorities will represent half of the U.S. population by 2050 [13]. Importantly, ethnic and racial minority groups have a much younger mean age than Whites and by 2050 will account for nearly 90% of the total population growth [13]. Immigration is an integral part of the history of the United States and the rich fabric of its society. Analysis from 2005 Census Bureau data illustrates that there are 35.2 million immigrants (documented and undocumented) living in the U.S. Currently, immigrants account for 12.1% of the total population in the U.S., the highest percentage in eight decades [14]. As this transformation of the nation's demographic occurs it will be critically important that improvements in health are equally distributed among all groups. (Hussein et al., 2006, p.19)

Even more reasons cause heath disparities. Disparities occur when resources are inequitably distributed across communities and groups. Social inequities directly affect the resources required to maintain health. The effects of social conditions such as income, education, occupation, family structure, service availability, sanitation, exposure to hazards, social support, racial discrimination, access to healthcare, and education, play a pivotal role as health indicators [15, 16]. The social determinants of socioeconomic status, environment, and behavior cause major differences in health outcomes such as longevity and an increase in preventable illnesses. Additionally they determine who gets seen by the healthcare system and when, and the quality of treatment received.

Socio-economic Factors: Data indicate that socioeconomic status (SES), -- whether measured by level of education, level of income or occupation -- , health status, and race/ethnicity are linked together in a web of factors that all contribute to poor health [16, 17]. Researchers have made an effort to untangle the confounding effects of health, race and SES [18]. However, even when SES factors are controlled there is still a disparity in clinical outcomes for minorities [8].

Physical Environment: The environment in which low-income individuals and minority groups live has a large impact on health conditions [19]. Residents of inner cities may lack access to medical care, parks for safe exercise, grocery stores or outlets with healthy food options. In addition, economically disadvantaged populations are more likely to reside in old houses containing lead pipes and leadbased paint, and to live in neighborhoods with higher concentrations of liquor stores and fastfood establishments [19].

Lifestyle and Behavior: Lifestyle behaviors are also associated with adverse health outcomes. Minority men with lower incomes and less education are more inclined to smoke, and use alcohol and drugs than those with higher incomes and more education [20]. Other studies show that tobacco products and alcohol are marketed more aggressively in low-income, minority communities [21]. Stress is another powerful determinant of health that manifests through behavior, socioeconomic status and environmental factors [20].

Each of these factors work together and along multiple pathways to affect health outcomes. These social determinants: socioeconomic, environmental, and behavioral all contribute to a bleak picture of overall life expectancy and health for minorities in this country. (Hussein et al., 2006, p.20)

The impact of health disparities has significantly impacted individuals, healthcare systems, and society and continues to do so. The notion of inequities undermines the trust needed between patient and provider; thereby potentially having negative impact on treatment and compliance. Health disparities result in premature death, disability, and a diminished quality of life. The lower quality of healthcare that is often a result of healthcare disparities jeopardizes productivity and viability in the workplace. This workplace loss may result in hindered economic and social advances for members of groups affected by disparities. Employers that contribute to reducing health disparities may decrease their direct and indirect costs for preventive, diagnostic and treatment services for chronic health problems such as heart disease and cancer before they develop, or treat them appropriately once they have manifested. Improving the quality of health that employees receive reduces the employer's annual health expenditures [22]. Additionally, the U.S. Bureau of Labor Statistics predicts that over the next decade racial and ethnic minorities will account for over 36% of the workforce, and an investment in their health will be vital to a thriving economy. Eliminating health disparities will provide our nation with citizens having better health, thus, greater potential to participate fully in school, employment, and the responsibilities and benefits of society. (Hussein et al., 2006, p.21)

As mentioned earlier in this document, it is important to distinguish between a healthcare disparity and a health disparity. While the former deals with access to care and quality of care received, the latter refers to a higher burden of illness, injury, disability, or mortality experienced by one population group in relation to another [2]. (Hussein et al., 2006, p.22)

In 2003, the overall mortality (death) rate in the United States for African-Americans was 30% higher than for Whites [12]. For the top three leading causes of death for all races and ethnicities (heart disease, cancer, and stroke), African-Americans suffer greater rates of mortality than their White counterparts [25]. Table 1 contains age-adjusted death rates and death ratios for the 10 leading causes of death. This table provides a foundation for further discussion of differences in health outcomes among various racial groups and serves as a comparison to Maryland state data (see Section IV: Health Disparities in Maryland). A comparison of the mortality ratios between minority groups and non-Hispanic Whites show large disparities for specific diseases. (Hussein et al., 2006, p.22)

The mortality ratios for chronic liver disease and diabetes for American Indians and Hispanics compared to non-Hispanic Whites shows a large mortality disparity [25]. Overall mortality rates are higher for African-Americans than non-Hispanic Whites; in particular, African-Americans have 10 times the rate of death from HIV than non-Hispanic White [25]. Taken together, these disparities contribute to a lower life expectancy for African-Americans than for Whites. A White infant born in 2004 was expected to live over five years longer than an African-American infant born the same year [26]. (Hussein et al., 2006, p.22)

For minority groups other than African-Americans, age-adjusted overall death rates for the leading causes of death are lower than White rates. This may be due to data limitations such as misclassification of minorities on death certificates and/or the return of older foreign-born minorities to their home countries. If there is misclassification of minorities as non-Hispanic Whites on death certificates, the count of minority deaths will be too low, and the minority death rate will be underestimated. The return of foreign-born minorities to their home country in the later stages of life may also underestimate minority populations with higher percentages of foreign-born residents. (Hussein et al., 2006, p.22)

The following series of points highlight health disparities for select diseases by minority groups compared to Whites. For the top three leading causes of death (heart disease, cancer, and stroke) minorities tend to have higher mortality rates than Whites.

Overall, minority and low-income populations have a disproportionate burden of death and disability from heart disease.

African-Americans are 30% more likely to die from heart disease than non- Hispanic Whites. Despite the fact that African-Americans have a lower age-adjusted prevalence of heart disease than Whites; only 10.1% of African-Americans compared to 11.9% of Whites have heart disease [27]. (Hussein et al., 2006, p.22)

As previously mentioned, a healthcare disparity refers to differences in insurance coverage, access, or quality of care that are not due to health need [7]. These disparities exist across diseases and settings (hospitals, dental offices, primary care clinics) and disparities in care are found by race, ethnicity, sex, age and for individuals with disabilities and other special healthcare needs. Ultimately, a reduction or elimination in healthcare disparities should help reduce health disparities seen in morbidity and mortality of minority groups compared to Whites. (Hussein et al., 2006, p.26)

The National Healthcare Disparities Report (NHDR) of 2005 by the Agency for Healthcare Research and Quality (AHRQ) found that while varying in magnitude by condition and population, disparities were observed in almost all aspects of healthcare [4]. African-Americans received poorer quality of care as compared to Whites in 43% of the AHRQ's core measures, while American Indians and Alaska Natives received poorer quality care than Whites in 38% of the core quality measures [4]. (Hussein et al., 2006, p.27)

Access to healthcare refers to "the degree to which people are able to obtain care from the healthcare system in a timely manner" [38]. The study of barriers in access often differentiates financial and non-financial barriers, and describes the extent to which individuals have a regular source of care. Financial barriers included whether or not an individual has insurance while nonfinancial barriers may refer to transportation, clinic hours and location of healthcare facilities. Having a regular source of care facilitates access to healthcare services and increases the likelihood of interacting with healthcare providers. In addition, having a regular source of care provides the entry point into the complex healthcare delivery system, particularly when specialty care is needed [39].

Insurance Coverage: Health insurance reduces out-of-pocket expenditures and has been shown to be the single most predictive indicator of utilization. Without coverage, many people find healthcare expensive and forego care even when needed.

The presence of health insurance provides access to a range of healthcare services, from preventive care to management of chronic health conditions. The uninsured have more problems getting care, tend to be diagnosed at later disease stages, and get less therapeutic care [40]. In addition, the uninsured often postpone seeking medical care and instead rely on emergency care to manage their day-to-day health [4]. Without coverage the uninsured are likely to die sooner and have poor health status [41]. (Hussein et al., 2006, p.27)

In 2004, 45.5 million adults lacked health insurance [42]. As Figure 5 shows, Hispanics are least likely to be insured. The disparities in health insurance coverage by racial and ethnic minorities translate into disparities in access to healthcare services. (Hussein et al., 2006, p.28)

Cultural differences between providers and patients and resulting differences in attitudes and behaviors can negatively influence treatment, follow-up, and compliance. Specifically, patients who speak a language other than English often have limited or no access to translation services, which can contribute to the inability to communicate with providers. Even when the patient speaks English, cultural barriers may make the healthcare system difficult to navigate [52]. Additionally, time and financial constraints may limit a provider's ability to listen to patients effectively and prompt them to rely on non-verbal observations such as race and ethnicity and other stereotypes. If a patient mistrusts the system they may withhold information and prompt the provider to succumb to stereotypes [8]. (Hussein et al., 2006, p.31)

Vital statistics data reveal that in 2004, age-adjusted all cause mortality for African-Americans was 989 per 100,000, which was 1.3 times higher than for Whites

758 per 100,000) [84]. For other minority groups, the age-adjusted death rates from vital statistics data are lower than White rates, but this may be due to some limitations in the data unique to those groups. Death rates in vital statistics data are determined from information on death certificates. If there is misclassification of minorities as non-

Hispanic Whites on death certificates, the count of minority deaths will be too low, and the minority death rate will be underestimated. This kind of error is uncommon for African-Americans, and more common for the other groups. A second source of underestimation of minority deaths would be the return of older foreign-born minority residents of the U.S. To their home country at the end of life. This would have a larger effect on the populations that have higher percentages of foreign-born residents. In Maryland, the percent foreign-born by racial and ethnic group is four percent for non-Hispanic Whites, nine percent for African-Americans, 16% for American Indians, 56% for Hispanics, and 72% for Asians [85]. (Hussein et al., 2006, p.42)

The mortality rate difference approach is the best way to see the overall societal impact of the disparity. This measure gives higher ranks to the more common causes of death, and gives a sense of the number of preventable deaths due to the disparity in that disease. (Hussein et al., 2006, p.42)

The key strategies for addressing Maryland health disparities may be accomplished in several ways. These strategies are based on an extensive search of the most current literature, best practices and research on health disparities. Most importantly, it is anchored in recommendations made by the people of Maryland during a series of public forums, annual conferences, and four advisory committees engaging more than 1,200 stakeholders representing diverse groups. The key strategies that emerged from the public discussions and dialogues are summarized below and grouped together based on common themes. (Hussein et al., 2006, p.67)

Statewide Collaborations: It is imperative to capitalize on the wealth of resources that currently exist in the state with regard to eliminating health disparities.

There are numerous groups and organizations in Maryland within the public, private, and academic sectors that are funded to address health disparities.

Establish a state-wide advisory group, bringing together all entities within the state with a mission to eliminate minority health disparities.

Foster community-institution partnerships in the state through a granting mechanism stipulating community involvement

Empower grassroots organizations and community groups to become equal partners with academic centers by educating them about their rights and responsibilities. (Hussein et al., 2006, p.42)

The key goal is that access is viewed as a process of receiving quality care, in a timely fashion and in a culturally and linguistically meaningful way.

Foster statewide collaborations between the state and key stakeholders such as hospitals, businesses, the insurance industry, safety net providers and consumers to assure that no Marylanders are without health coverage.

Remove physical, transportation, cultural, linguistic and fiscal barriers to healthcare.

Develop evidence-based guidelines should be developed and used in the clinical setting for all patients.

Assure treatment success by applying culturally consistent patient-centered interventions when implementing evidence-based guidelines. (Hussein et al., 2006, p.42)

It is critical that complete and accurate racial and ethnic information becomes part of all health and healthcare data systems. Reports on health status and healthcare quality must be analyzed by race and ethnicity in order to identify disparities and to track progress.

Develop data on racial and ethnic minority groups and sub-groups for whom data is presently inadequate.

Achieve complete and transparent data collection system in compliance with state and national standards.

Collect data on race and ethnicity, by self-identification where possible, in all health data systems, so that health status and healthcare access and quality can be assessed by race and ethnicity.

Standardize Maryland's health data systems methods of data collection and analysis, so that comparisons of reports from different systems can be made, and so that data might be combined across data systems for analysis. (Hussein et al., 2006, p.69)

In order to fund these changes and programs in Maryland, several changes must be made. The multitude of factors that need to be addressed in order to eliminate health disparities demand extensive resources, which is a major challenge given limited state and federal funds.

Fund pilot projects statewide that stand to have the greatest impact on reducing health disparities (such as oral health, cancer prevention, AIDS, etc.).

Fund demonstration projects within DHMH that will target major areas of health disparities in the state.

Make available funds to the state's public education system in optimizing educational opportunities in K-12 programs and in two and four-year colleges.

Foster partnerships and collaborations between centers for health disparities around the state to maximize the resources and impact of these centers.

Provide resources to develop an effective infrastructure for the Office of Minority

Health and Health Disparities to implement recommendations to implement programs to eliminate health disparities. (Hussein et al., 2006, p.69)

Conclusion number of reasons contribute to heath disparities, Hussein et al. (2006) contend.

When, for whatever reason, some "thing" distributes resources inequitably across communities and groups - disparities occur. The resulting social inequities, in turn, directly affect the resources required to maintain health. "The effects of social conditions such as income, education, occupation, family structure, service availability, sanitation, exposure to hazards, social support, racial discrimination, access to healthcare, and education, play a pivotal role as health indicators" (Hussein et al., p. 20). In turn, the social determinants of socioeconomic status, environment, and behavior traditionally contribute to major differences in health, including longevity and an increase in preventable illnesses.

These social determinants establish:

Who benefits from the healthcare system, as well as when and where, recipients of health care services receive the services the quality of treatment received (Hussein et al., 2006, p. 20).

Ultimately, albeit, for access to health care to be effective, it must live up to the definition the Institute of Medicine purports: "the timely use of personal health services to achieve the best possible health outcomes...." (Healthy Maryland Project 2010, 2001, p. 12). Then an donly then will it cease from being not only Maryland's major problem but be less of a national, state and local problem. During the next section, the Methods and Results, the researcher relates more of the problem and potential plans to address the concern relating to the health care disparity in Maryland.

CHAPTER 3

METHODOLOGY map of the world that does not include Utopia is not worth even glancing at, for it leaves out the one country at which Humanity is always landing"

Oscar Wilde (1854-1900) (Quindlen, as cited in Columbia World, 1996).

3.1: Introduction

Similar to the way a map guides a person to a particular destination, the methodology for a study, such as this DRP, serves as a guide for the researcher to complete his/her study.

Table 1 portrays components of Qualitative research.

Table 1: Qualitative Research Components (Qualitative research: Approaches...," 2008)

Hypotheses

Precise hypotheses stated at the outset

Definitions

Precise definitions stated at the outset

Type of Data Generated

Numerical scores

Reliability

Much attention to assessing and improving reliability of scores obtained from instruments

Validity

Assessment of validity through a variety of procedures with reliance on statistical indices

Sampling

Random techniques for obtaining meaningful samples

Description of Procedures

Precisely describing procedures

Controlling Extraneous

Variables

Design or statistical control of extraneous variables

Controlling for Procedural Bias

Specific design control for procedural bias

Summary of Results

Statistical summary of results

Description of Phenomena

Breaking down complex phenomena into specific parts for analysis

Handling of Phenomena

Willingness to manipulate aspects, situations, or conditions in studying complex phenomena exploratory study, an empirical research approach, focuses on a contemporary phenomenon, process, social group, event, or organization, with the aim to proffer a detailed description, and/or spotlight a phenomenon or social process. Methods utilized in a case study include: (Qualitative research: Approaches...," 2008).

Observation, text analysis, document analysis, archives (but also questionnaires). (Qualitative research: Approaches...," 2008)

"case" may consist of a, classroom/team, school/organization, program, activity, event, activity, ongoing process or an individual. The following denote the three various types of cases:

Intrinsic: understanding specific individual or situation,

Instrumental: studying particular case as a means to larger goals (drawing general conclusions).

Multiple/collective: studying multiple cases as part of overall study.

Qualitative research: Approaches...," 2008)

Hypotheses

Precise hypotheses stated at the outset

Hypotheses that emerge as study develops

Definitions

Precise definitions stated at the outset

Definitions in context or as study progresses

Type of Data Generated

Numerical scores

Narrative description

Reliability

Much attention to assessing and improving reliability of scores obtained from instruments

Preference for assuming that reliability of inferences is adequate

Validity

Assessment of validity through a variety of procedures with reliance on statistical indices

Assessment of validity through cross-checking sources of information (triangulation)

Sampling

Random techniques for obtaining meaningful samples

Expert informant (purposive samples)

Description of Procedures

Precisely describing procedures

Narrative/literary descriptions of procedures

Controlling Extraneous

Variables

Design or statistical control of extraneous variables

Logical analysis in controlling or accounting for extraneous variables

Controlling for Procedural Bias

Specific design control for procedural bias

Primary reliance on researcher to deal withprocedural bias

Summary of Results

Statistical summary of results

Narrative summary of results

Description of Phenomena

Breaking down complex phenomena into specific parts for analysis

Holistic description of complex phenomena

Handling of Phenomena

Willingness to manipulate aspects, situations, or conditions in studying complex phenomena

Unwillingness to tamper with naturally occurring phenomena (Fraenkel & Wallen, 2006)

Methodology Section

Methodology (approaches) vs. Methods

Methodologies serve as lenses through which you approach your research questions and methods

Often we only pay attention to methods (e.g. questionnaire, interview, focus group)

Rigour improves when paying attention to methodologies as well (reflexivity)

Approaches to Qualitative Research

Several approaches/methodologies-Grounded theory, case study, action research, mixed methods

Within each methodology several methods could be used (depending on your research questions)

Grounded Theory

Grounded Theory (1)

Definition: research method intended to generate a theory that is 'grounded in data systematically gathered and analyzed'

Aim: develop theories/explain a process regarding social phenomena

Not to test or verify existing theory

Methods: interview, focus group, observation

Grounded Theory (2)

Characteristics

Iterative approach

Cycles of simultaneous data collection and analysis previous cycle informs next data collection etc.

Theoretical sampling

Sample is not set at the outset but selected purposively as study progresses

Constant comparison

Data-analysis: emerging theoretical concepts are continually refined with 'fresh' examples

Open coding (generating themes + Axial coding (generating

Grounded Theory (3)

Pitfalls

Grounded theory analysis, NOT design

Constant comparison applied, but not iterative method or theoretical sampling

Applying predetermined themes

Emphasis must be on 'emergent' theory

Analysis Interruptus'

Thematic description without theory development

Case Study

References

Case Study (1)

Definition: An empirical research approach focusing on either a current phenomenon, process, event, social group or organization

Aim: Provide a thorough description, and/or highlight a social process or a phenomenon

Methods: interview, observation, text analysis, document analysis, archives (but also questionnaires)

Case Study (2)

The Case' Interviews Observations Document Analysis Questionnaires

Case Study (3)

What could be a 'case':

One individual, classroom/team, school/organization, program, event, activity, ongoing process different types

Intrinsic: understanding specific individual or situation

Instrumental: studying particular case as a means to larger goals (drawing general conclusions)

Multiple/collective: studying multiple cases as part of overall study

Action Research

Action Research (1)

Definition: research which is designed, carried out, and integrated by the participants in partnership with then researchers

Aim:solving a problem or obtaining information in order to inform local practice creating positive change

Methods: both qualitative and quantitative

Action Research (2)

Features

Design-Based Research

Mixed Methods

Mixed Methods (1)

Definition:

Aim: combining elements from both qualitative and quatitative paradigm to produce converging findings in the context of a complex reearch questions

Methods: both qualitative and quantitative

Mixed Methods (2)

Important to consider

Explicit strategy which justifies

Sequence of methods

Priority among methods

Nature of timing and integration

Using both qualitative and quantitative paradigm: how do these communicate

METHODS

Interviews

Focus Groups

Interviews (2)

Why do we use interviews?

To understand the "how," "what, and "why" (e.g., opinion, perception, attitude, process)

To understand sensitive issues, from the perspective of the respondents

To develop an in-depth understanding of a social phenomenon or of particular perspectives

To understand how people make sense of the world around them or of a particular situation

To measure the occurrence on non-occurrence of an event, experience, perception etc.

Interviews (3)

Types of interviews

Unstructured

Informal, conversational interview -no predetermined questions are asked, in order to remain as open and adaptable as possible to the interviewee's nature and priorities

Structured

Interviewer asks respondents the same series of pre-established questions in the same order

Semi-structured series of open ended questions are developed that reflect the researcher's understanding of theoretical perspective

Interviews (4)

Types of questions you might ask

Behaviors -what a person has done or is doing.

Opinions/values -what a person thinks about the topic.

Feelings -what a person feels rather than what a person thinks.

Knowledge -to get facts about the topic.

Experiential - examples of how people have experienced the world

Sensory -what people have seen, touched, heard, tasted or smelled.

Background/demographics -standard background questions, such as age, education, etc.

Focus Groups

References

Barbour (2005)

Kitzinger (1995)

Focus Groups (3)

Appropriateness

Focus groups are more labour intensive and expensive than the more commonly used questionnaire approach

Focus groups are useful when it comes to investigating what participants think, but they excel at uncovering why participants think as they do influence of INTERACTION

Sampling Issues

References

Kuper (2008)*

Fraenkel & Wallen (Ch18)

Sampling in Qualitative Research (1)

Sampling = Who to include in your study?

Sample should be broad, limitations should be described

Acknowledge context of sample

Usually no predetermined sample size: sampling stops when thorough understanding has been reached (saturation)

Sampling in Qualitative Research (2)

Some different types

Typical case

Most ordinary, usual cases

Deviant case

Most extreme cases

Critical case

Predicted to be information rich

Maximum variation

Theoretical

Of whom researcher predicts will add new perspectives

How to improve quality

Triangulation

Multiple theories, data and methods

Reflexivity

Recognition of the influence a researcher brings to the research process

Using a clear defined approach and THEORY

In the end: making as clear as possible what you did, why, and where you were coming from but beware!

Barbour (2001)

Uncritical adoption of a range of technical fixes'

Purposive sampling, grounded theory, multiple coding, respondent validations

Techinical fixes will achieve little unless they are embedded in a broader understanding of the rationale and assumptions behind qualitative research' in many cases can be very difficult and costly for the airport and aircraft's operators. This article looks into the basic aspects of a recovery, addresses the complexities of a recovery incident and emphasizes why airports and airlines need to better prepared to handle the unfortunate event of a disabled machine.

3.1: Introduction

This is where you might give a brief introduction to the specific nature of your intended research - what data you intend you use and what your overall methods and techniques will be 3.2: Data Used

Discuss the data that you will be using. Is it primary or secondary data? Will you be compiling the data your self (from questionnaires for example) or using census data from a government source?). What are the spatial and temporal characteristics of the data? Are there any known or anticipated sources of error in the data?

3.2.1: Spatial and temporal characteristics

Discuss specific data characteristics within a sub-section

3.3: Methods and techniques

These may have their own section of they are different enough. Some literature references might be used here - cited appropriately.

3.3.1: A specific method

Use subsections to discuss a specific topic or technique

You can finish with a brief summary and then a lead-in to the next chapter

In the section of Research Design and Methodology, you explain your research design and how/why it will be useful as a means to help you answer your research questions. Please explain where (multiple sources.) you will collect the data and how you're going to analyze the information.

You can organize this section by doing the following three things:

First, you have to say what research (qualitative or quantitative) research you wish to use. Under the new guidelines, you only can conduct a qualitative research study.

Second, you have to say which specific research design you wish to use. Case Study could fit it the new guidelines nicely.

Third and the last, you have to describe the data collection method and data analysis method.

Case study has been recognized as a strategy of research methodologies, widely applied to a variety of disciples of study. Instead of using large samples and following a rigid protocol to examine a limited number of variables, case study methods involve identifying the case of study within a bounded system, providing a systematic way of looking at the event, using multiple sources of evidence in data collection, analyzing information, and describing the in-depth picture of setting or context for the case (Aday, 1996; Creswell, 1998). Consequently, the researcher may obtain a better understanding of why and how the instance happened, and what might become worthy and imperative to examine more extensively in future research.

A case study is collecting a range of different kinds of evidence, such as (interviews, surveys,) observations, company's written documents/reports, artifacts, videotapes, DVD, emails, listserves, newsgroups, Blogs, achieved discussion lists, etc., in order to get the best, thorough answers to the research questions. Each source of evidence has its strengths and weakness, and any one source is unlikely to be sufficient on its own. It does not mean that one set of evidence is wrong. The researcher would have higher confidence in drawing inference when several sets of evidence converge on what the phenomenon is all about. The use of multiple sources of evidence is a main characteristic of case study research.

In the New York Times, May 14, 1994 edition, Anna Quindlen wrote about Dr. Mack

Lipkin, Jr., who at the time, led a crusade to include study of patient-doctor relationships in the medical school curriculum. Quindlen stressed that both doctor and patient need "...to be treated like a whole person, not just an eye, an ear, a nose or a throat" (Quindlen, as cited in Columbia World, 1996).

For those noted in this analysis chapter, experiencing the ensuing disparities from not having access to Maryland's health care, the researcher finds, the need for these individuals to be treated like a whole person...like a real individual who matters repeatedly surfaces.

4.3: Disparity Financial Impacts Morbidity Rate

Table 1 relates the percentage of individuals without health insurance coverage at the time of interview, for at least part of the year, or for more than a year, by selected demographic characteristics in the U.S. during January-September 2005.

Table 1: Persons Lacking Health Insurance ((Maryland Plan to Eliminate..., 2006, p. 28)

Uninsured (1) for Uninsured (1) for Uninsured (1) at the at least part of the more than a year

Selected Characteristics time of the interview past year (2)

Age

All Ages

Under 65 years

Under 18 years

18-64 years

65 years and over Sex

Male

Female

Race/Ethnicity

Hispanic or Latino

Non-Hispanic, White

Non-Hispanic. Black Non-Hispanic. Other/Multiple races

Source: Adapted from Family Core component of the 2005 National Health Interview Survey. The estimates for 2005 were based on data collected from January through September [43].

A person was defined as uninsured if he or she did not have any private health insurance, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), state-sponsored or other government-sponsored health plan, or military plan. A person was also defined as uninsured if he or she had only Indian Health Service coverage or had only a private plan that paid for one type of service such as accidents or dental care.

A year is defined as the 12 months prior to interview.

4.4: Disparity Differences in Cost Impact

Financial and Non-Financial Barriers

Figure 2 depicts a number of nonfinancial barriers to access to Maryland's Health Care. These include, but are not limited to transportation, clinic hours and location of healthcare facilities.

Figure 2: Non-Financial Barriers to Access to Maryland's Health Care (Maryland Plan to Eliminate..., 2006, p. 27)

Table 1: "Age-Adjusted Mortality Rates (per 100,000) and Mortality Ratios for the 10 Leading Causes of Death, United States 2003" ((Maryland Plan to Eliminate..., 2006, p. 23)

Cause of Death White,

Non-

Hispanic

Death Rate Black

Death

Rate Black White

Ratio AIAN

Death

Rate AlANA/White

Ratio Asian/

PI

Death

Rate API/White

Ratio Hispanic

Death

Rate Hispanic/

White

Ratio All Cause

Mortality 826.1-1.065.9-1.3 685.0-0.8 465.7-0.6 621.2-0.75 Diseases of heart 230.9 300.2-1.3 160.2-0.7 127.6-0.6 173.2-0.75 Malignant neoplasms 192.4 233.3-1.2 119.3-0.6 113.5-0.6 126.6-0.66 Stroke 51.7-74.3-1.4-34.6-0.7-45.2-0.9-40.5-0.78 Chronic lung disease 47.0-30.1-0.6-31.7-0.7-16.2-0.3-20.2-0.43 Influenza and pneumonia 22.0-23.3-1.1-24.1-1.1-17.3-0.8-18.4-0.84 Chronic liver disease 9.0-8.4-0.9-22.6-2.5-3.0-0.3-14.7-1.63 Diabetes 22.1-49.2-2.2-43.7-2.0-17.3-0.8-35.0-1.58 HIV 2.0-21.3-10.7-2.5-1.3-0.7-0.4-5.9-2.95 Accidents 38.8-36.1-0.9-56.4-1.5-18.0-0.5-30.6-0.79 Suicide 12.7-5.2-0.4-10.0-0.8-5.6-0.4-5.6-0.44 Homicide 2.7-21.0-7.8-7.3-2.7-2.9-1.1-7.7-2.85

Discussion of Results

The financial, as well as the non-financial barriers to access to Maryland's Health Care

For those noted in this analysis chapter, experiencing the ensuing disparities from not having access to Maryland's health care, the researcher finds, the need for these individuals to be treated like a whole person...like a real individual who matters repeatedly surfaces.

During the next chapter of this study, the fourth and final chapter, along with the researcher relates a number of CHAPTER IV

DISCUSSION, CONCLUSION and RECOMMENDATION

One]...may have a map in which every feature that can be named, every hill, brook, crossroads, is crowded in; in the effort to show the reader the lay of the land, the shape of the mountain systems, the relations of drainage, relief, communications, and so on.

Both kinds are useful, depending on the needs of the user"

Crane Brinton (1898-1968), U.S. historian, educator (Brinton, as cited in Columbia World, 1996).

4.1: Introduction

In this study, which addressed the unsettling challenges that occur in Maryland due to the disparity in access to health care services between rural and urban residence in Maryland, along with the impact of the lack of financial resources relating to this concern, the "bottom line" for Maryland to develop a "map" to/for positive changes depends on the needs of the user.

In addressing the research questions developed this study, the researcher determined the validity of this study's hypothesis: If the challenges currently attributing to disparities in access to health care services between rural and urban residence in Maryland are effectively addressed and positive changes implemented to counter these disparities, then the disparities, along with the impact of the lack of financial resources relating to this concerns will begin to dissipate and/or decrease.

During the study, the researcher examined the following areas, initially introduced in this study's introduction:

The financial impact on access to health care in rural vs. urban areas in Maryland in terms of mortality rate.

The financial impact on access to health care in rural vs. urban areas in Maryland in terms of morbidity rate.

The differences in the impact of cost on access to health care in rural vs. urban areas in Maryland in terms of the ethnic makeup of the populations served.

4.2: Discussion

This discussion section recounts details from the literature review

Financial Impacts Mortality Rate

Efforts to address health care disparities in rural areas are often made difficult by struggling economies and limited financial and human resources. Compared with the State overall, Maryland's rural communities tend to have fewer healthcare organizations and professionals, higher rates of chronic disease and mortality, and larger Medicare and Medicaid populations. Evidence indicates that rural populations fare worse in many health and economic indicators, and do not receive the same quality, effective, and equitable care as their suburban counterparts. A growing portion of the rural population suffers from chronic diseases. The costs for the State to care for this population will increase over the next few decades unless attention and funding are directed toward improvements in preventive health (Jenkins et al., 2007, P.1).

The rural health system could improve residents' quality of life more effectively if access to health care providers, prescription medications, and health education improved. Unless action is taken now, the future burden of chronic disease in many rural communities could become enormous. (Jenkins et al., 2007, P.1) the uninsured and under-insured are more likely not to seek treatment until a health problem becomes a serious medical issue. This subset of the population experiences poorer health outcomes and higher mortality rates, and must pay for their care out-of-pocket, placing strain on their finances. Nationally, low-income rural adults with private coverage fare worse in measures of healthcare access than urban low-income adults with private insurance. Medicaid and Medicare enrollments are higher in the federally-designated rural jurisdictions compared to the State. (Jenkins et al., 2007, P.14)

Improving availability of care means ensuring there are enough providers and facilities available to provide sufficient care.The poorer health outcomes and rates of chronic disease in Maryland's rural areas suggest there may not be enough providers or health delivery sites available. Some of the existing programs to increase the health care workforce include loan-assistance repayment programs, J-1 visa waivers, the National Health Service Corps program, and the National Interest Waiver Program. Although there are Federally Qualified Health Centers (FQHCs) and other facilities throughout the State that provide health care to anyone regardless of income, there are rural areas in Maryland without health centers and where existing health centers do not have the capacity to meet the need. (Jenkins et al., 2007, P.25)

Disparity Financial Impacts Morbidity Rate

Along with the numerous obstacles providers and patients face, numerous causes contribute to the health care disparities in rural and urban Maryland. A combination of unique factors that Marylanders face is economic factors, cultural and social differences, education, isolation and job opportunities. (Wasserman, 2007, P. 13) Rural residents tend to be poorer and more likely to live at the poverty level. On the average, per capita income is $7,417 lower than in urban areas. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty. People who live in rural America rely more heavily on the federal Food Stamp Program. Alcohol abuse and use of smokeless tobacco are significant problems among rural youth. DUI arrests are significantly greater in rural communities. (Wasserman, 2007, P. 14)

Rural Maryland is losing clout to the urban centers," he says. "Every election a few more delegates came in from Baltimore and suburban counties, and fewer from rural ones." (Farquhar, 2006, Para. 3) "The biggest job of the caucus is teaching the urban legislators about living in rural areas," says Flake. (Farquhar, 2006, Para. 10) Beyond just promoting agriculture, these caucuses are discussing issues such as the lack of healthcare and social services, a weakening tax base, water needs, housing costs and economic development -- the major concerns facing rural America. (Farquhar, 2006, Para. 11)

Attracting doctors is also a problem in rural Maryland. Without the facilities and economic base to build a practice, most young physicians remain in the larger cities. Even doctors from rural areas who want to return find it difficult to maintain a practice because many of their clients are on Medicaid, which doesn't always reimburse the full cost of services. (Farquhar, 2006, Para. 19)

Affordability is closely linked with access, as lack of health insurance bars many from needed health care. Limited health insurance and out-of-pocket expenses make it especially difficult for the rural population to afford the preventive and primary care they need. Prohibitively expensive co-pays and high deductibles may prevent residents with health insurance from being able to afford health care visits. Problems of higher unemployment and lower income in rural areas of Maryland exacerbate the affordability problem. (Jenkins et al., 2007, P.26)

The Cancer Prevention, Education, Screening and Treatment Program was created under the Cigarette Restitution Fund (CRF) and seeks to reduce death and disability due to cancer in Maryland through implementation of local public health and statewide academic health center initiatives. The mission of the Cancer Prevention, Education, Screening and Treatment Program is to reduce the burden of cancer among Maryland residents through enhancement of cancer surveillance, implementation of community-based programs to prevent and/or detect and treat cancer early, enhancement of cancer research, and translation of cancer research into community-based clinical care. The Cancer Prevention, Education, Screening and Treatment Program envisions a future in which all residents of Maryland can lead healthy, productive lives free from cancer or disability due to cancer. (M00F03.06, 2008, P.1)

Disparity Differences in Cost Impact

To best assess the disparities in health in Maryland, one needs to assess health outcomes, care and treatment, along with the supporting system. The report by Hussein (2006) defines a health disparity as a difference in the burden of illness, injury, disability, or mortality between one population group and another. A healthcare disparity can be defined as differences in insurance coverage, access to or quality of healthcare services.

The causes of these disparities are myriad and complex, and may emerge from any number and combination of patient, healthcare system, and societal factors. This first Maryland Plan to Eliminate Minority Health Disparities addresses both types of disparities. (Hussein et al., 2006, p.13)

The impact of health disparities has significantly impacted individuals, healthcare systems, and society. The notion of inequities undermines the trust needed between patient and provider; thereby potentially having negative impact on treatment and compliance. Health disparities result in premature death, disability, and a diminished quality of life. The lower quality of healthcare that is often a result of healthcare disparities jeopardizes productivity and viability in the workplace. This workplace loss may result in hindered economic and social advances for members of groups affected by disparities. Employers that contribute to reducing health disparities may decrease their direct and indirect costs for preventive, diagnostic and treatment services for chronic health problems such as heart disease and cancer before they develop, or treat them appropriately once they have manifested. Improving the quality of health that employees receive reduces the employer's annual health expenditures [22]. (Hussein et al., 2006, p.21)

It is important to distinguish between a healthcare disparity and a health disparity. While the former deals with access to care and quality of care received, the latter refers to a higher burden of illness, injury, disability, or mortality experienced by one population group in relation to another [2]. (Hussein et al., 2006, p.22) Access to healthcare refers to "the degree to which people are able to obtain care from the healthcare system in a timely manner" [38]. The study of barriers in access often differentiates financial and non-financial barriers, and describes the extent to which individuals have a regular source of care. Financial barriers included whether or not an individual has insurance while non-financial barriers may refer to transportation, clinic hours and location of healthcare facilities. Having a regular source of care facilitates access to healthcare services and increases the likelihood of interacting with healthcare providers. In addition, having a regular source of care provides the entry point into the complex healthcare delivery system, particularly when specialty care is needed [39]. (Hussein et al., 2006, p.27)

Health care reform in the United States has proven to be one of the most complex challenges facing lawmakers and private citizens today. Although there is widespread agreement that the system is in disarray and in dire need of fundamental reform, the core problems of affordability and access continue to steadily worsen. The extent of the national health care crisis is reflected in the fact that although health care annually consumes some sixteen percent of the nation's GDP (or $2.0 trillion), (1) 46.5 million Americans under the age of sixty-five are currently uninsured.

Financial Impacts Mortality Rate

Efforts to address health care disparities in rural areas are often made difficult by struggling economies and limited financial and human resources. Compared with the State overall, Maryland's rural communities tend to have fewer healthcare organizations and professionals, higher rates of chronic disease and mortality, and larger Medicare and Medicaid populations. Evidence indicates that rural populations fare worse in many health and economic indicators, and do not receive the same quality, effective, and equitable care as their suburban counterparts. A growing portion of the rural population suffers from chronic diseases. The costs for the State to care for this population will increase over the next few decades unless attention and funding are directed toward improvements in preventive health. (Jenkins et al., 2007, P.1)

The rural health system could improve residents' quality of life more effectively if access to health care providers, prescription medications, and health education improved. Unless action is taken now, the future burden of chronic disease in many rural communities could become enormous. (Jenkins et al., 2007, P.1) the uninsured and under-insured are more likely not to seek treatment until a health problem becomes a serious medical issue. This subset of the population experiences poorer health outcomes and higher mortality rates, and must pay for their care out-of-pocket, placing strain on their finances. Nationally, low-income rural adults with private coverage fare worse in measures of healthcare access than urban low-income adults with private insurance. Medicaid and Medicare enrollments are higher in the federally-designated rural jurisdictions compared to the State. (Jenkins et al., 2007, P.14)

Improving availability of care means ensuring there are enough providers and facilities available to provide sufficient care. The poorer health outcomes and rates of chronic disease in Maryland's rural areas suggest there may not be enough providers or health delivery sites available. Some of the existing programs to increase the health care workforce include loan-assistance repayment programs, J-1 visa waivers, the National Health Service Corps program, and the National Interest Waiver Program. Although there are Federally Qualified Health Centers (FQHCs) and other facilities throughout the State that provide health care to anyone regardless of income, there are rural areas in Maryland without health centers and where existing health centers do not have the capacity to meet the need. (Jenkins et al., 2007, P.25)

Disparity Financial Impacts Morbidity Rate

The challenge for Maryland in access to healthcare encompasses combination of unique factors, including economic factoers, cultural and social differences, education, isolation and job opportunities (Wasserman, 2007, p. 13). Rural residents tend to be poorer and more likely to live at the poverty level. On the average, per capita income is $7,417 lower than in urban areas. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty. People who live in rural America rely more heavily on the federal Food Stamp Program. Alcohol abuse and use of smokeless tobacco are significant problems among rural youth. DUI arrests are significantly greater in rural communities. (Wasserman, 2007, P. 14)

Rural Maryland is losing clout to the urban centers," he says. "Every election a few more delegates came in from Baltimore and suburban counties, and fewer from rural ones." (Farquhar, 2006, Para. 3) "The biggest job of the caucus is teaching the urban legislators about living in rural areas," says Flake. (Farquhar, 2006, Para. 10) Beyond just promoting agriculture, these caucuses are discussing issues such as the lack of healthcare and social services, a weakening tax base, water needs, housing costs and economic development -- the major concerns facing rural America. (Farquhar, 2006, Para. 11)

Attracting doctors is also a problem in rural Maryland. Without the facilities and economic base to build a practice, most young physicians remain in the larger cities. Even doctors from rural areas who want to return find it difficult to maintain a practice because many of their clients are on Medicaid, which doesn't always reimburse the full cost of services. (Farquhar, 2006, Para. 19)

Affordability is closely linked with access, as lack of health insurance bars many from needed health care. Limited health insurance and out-of-pocket expenses make it especially difficult for the rural population to afford the preventive and primary care they need. Prohibitively expensive co-pays and high deductibles may prevent residents with health insurance from being able to afford health care visits. Problems of higher unemployment and lower income in rural areas of Maryland exacerbate the affordability problem. (Jenkins et al., 2007, P.26)

The Cancer Prevention, Education, Screening and Treatment Program was created under the Cigarette Restitution Fund (CRF) and seeks to reduce death and disability due to cancer in Maryland through implementation of local public health and statewide academic health center initiatives. The mission of the Cancer Prevention, Education, Screening and Treatment Program is to reduce the burden of cancer among Maryland residents through enhancement of cancer surveillance, implementation of community-based programs to prevent and/or detect and treat cancer early, enhancement of cancer research, and translation of cancer research into community-based clinical care. The Cancer Prevention, Education, Screening and Treatment Program envisions a future in which all residents of Maryland can lead healthy, productive lives free from cancer or disability due to cancer. (M00F03.06, 2008, P.1)

Disparity Differences in Cost Impact

In order to assess the disparities in health in Maryland, it is necessary to look at health outcomes, care and treatment, and the supporting system; therefore, for this report disparity is defined in the context of burden and care. A health disparity can be defined as a difference in the burden of illness, injury, disability, or mortality between one population group and another [2]. A healthcare disparity can be defined as differences in insurance coverage, access to or quality of healthcare services [2]. The causes of these disparities are myriad and complex, and may emerge from any number and combination of patient, healthcare system, and societal factors. This first Maryland Plan to Eliminate Minority Health Disparities addresses both types of disparities. (Hussein et al., 2006, p.13)

In the past, and even now, health disparities significantly impact individuals, healthcare systems, and society. The notion of inequities undermines the trust needed between patient and provider; thereby potentially having negative impact on treatment and compliance. Health disparities result in premature death, disability, and a diminished quality of life. The lower quality of healthcare that is often a result of healthcare disparities jeopardizes productivity and viability in the workplace. This workplace loss may result in hindered economic and social advances for members of groups affected by disparities. Employers that contribute to reducing health disparities may decrease their direct and indirect costs for preventive, diagnostic and treatment services for chronic health problems such as heart disease and cancer before they develop, or treat them appropriately once they have manifested. Improving the quality of health that employees receive reduces the employer's annual health expenditures [22]. (Hussein et al., 2006, p.21)

It is important to distinguish between a healthcare disparity and a health disparity. While the former deals with access to care and quality of care received, the latter refers to a higher burden of illness, injury, disability, or mortality experienced by one population group in relation to another [2]. (Hussein et al., 2006, p.22) Access to healthcare refers to "the degree to which people are able to obtain care from the healthcare system in a timely manner" [38]. The study of barriers in access often differentiates financial and non-financial barriers, and describes the extent to which individuals have a regular source of care. Financial barriers included whether or not an individual has insurance while non-financial barriers may refer to transportation, clinic hours and location of healthcare facilities. Having a regular source of care facilitates access to healthcare services and increases the likelihood of interacting with healthcare providers. In addition, having a regular source of care provides the entry point into the complex healthcare delivery system, particularly when specialty care is needed [39]. (Hussein et al., 2006, p.27)

Health care reform in the United States has proven to be one of the most complex challenges facing lawmakers and private citizens today. Although there is widespread agreement that the system is in disarray and in dire need of fundamental reform, the core problems of affordability and access continue to steadily worsen. The extent of the national health care crisis is reflected in the fact that although health care annually consumes some sixteen percent of the nation's GDP (or $2.0 trillion), (1) 46.5 million Americans under the age of sixty-five are currently uninsured.

5.2: Conclusion

Maryland's rural communities have fewer healthcare organizations and professionals, higher rates of chronic disease and mortality, and larger Medicare and Medicaid populations. Rural populations have declining health care access and economic barriers. Consequently, individuals in Maryland may not receive the same quality, effective, and equitable care as the urban and suburban areas. As a result, a large portion of the rural population suffers from chronic diseases. The costs for the State to care for this population will increase over the next few decades unless attention and funding are directed toward improvements in preventive health (Jenkins et al., 2007, P.1).

The rural health system could improve residents' quality of life more effectively if access to health care providers, prescription medications, and health education improved. (Jenkins et al., 2007, P.1) the uninsured and under-insured are more likely not to seek treatment until a health problem becomes a serious medical issue. This subset of the population experiences poorer health outcomes and higher mortality rates, and must pay for their care out-of-pocket, placing strain on their finances. Nationally, low-income rural adults with private coverage fare worse in measures of healthcare access than urban low-income adults with private insurance. Medicaid and Medicare enrollments are higher in the federally-designated rural jurisdictions compared to the State. (Jenkins et al., 2007, P.14)

Affordability is closely linked with access, as lack of health insurance bars many from needed health care. Limited health insurance and out-of-pocket expenses make it especially difficult for the rural population to afford the preventive and primary care they need. Prohibitively expensive co-pays and high deductibles may prevent residents with health insurance from being able to afford health care visits. Problems of higher unemployment and lower income in rural areas of Maryland exacerbate the affordability problem. (Jenkins et al., 2007, P.26)

The impact of health disparities has significantly impacted individuals, healthcare systems, and society. The notion of inequities undermines the trust needed between patient and provider; thereby potentially having negative impact on treatment and compliance. Health disparities result in premature death, disability, and a diminished quality of life. Employers that contribute to reducing health disparities may decrease their direct and indirect costs for preventive, diagnostic and treatment services for chronic health problems such as heart disease and cancer before they develop, or treat them appropriately once they have manifested. Improving the quality of health that employees receive reduces the employer's annual health expenditures [22]. (Hussein et al., 2006, p.21)

Financial barriers must be overcome to create better access to healthcare in rural and urban areas. Whether or not an individual is covered by health insurance often proves to be a financial barrier while non-financial barriers may refer to transportation, clinic hours and location of healthcare facilities. Having a regular source of care facilitates access to healthcare services and increases the likelihood of interacting with healthcare providers. In addition, having a regular source of care provides the entry point into the complex healthcare delivery system, particularly when specialty care is needed [39]. (Hussein et al., 2006, p.27) for the U.S. To overcome the staggering statistics of 46.5 million Americans under the age of 65, currently uninsured major developments must be put in place. Health care reform in the United States has proven to be one of the most complex challenges facing lawmakers and private citizens today. Although there is widespread agreement that the system is in disarray and in dire need of fundamental reform, the core problems of affordability and access continue to steadily worsen. The extent of the national health care crisis is reflected in the fact that although health care annually consumes some sixteen percent of the nation's GDP (or $2.0 trillion). (Chirba-Martin, 2008, Para. 1)

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