Cost, Structural Barriers Limit Equal Access to Health Care in Inflammatory Skin Disease

Black and Hispanic patients living with chronic inflammatory skin disease (CISD) have more barriers to care compared with White patients with CISD, according to a recent study.

A cross-sectional evaluation published in the Journal of the American Academy of Dermatology finds Black and Hispanic patients living with chronic inflammatory skin disease (CISD) were disproportionally affected by cost and structural barriers to health care than White patients.

The study included a total US cohort of 16,986 patients living with CISDs. The population was made up largely of older patients (median age, 55.6; interquartile range [IQR], 38.8-67.3 years) and were mostly female (73.7%). The data was collected by a survey of participants with CISDs in the National Institute of Health’s All of Us Research Program.

White patients were often college educated (69.4%), had a household income greater than $100k (42%), had employer or union insurance (48.1%), and were from the Northeast or Midwest (43.3% and 37.9%, respectively).

Additionally, Black and Hispanic patients were more often on Medicaid (26.1% and 28.5%, respectively), had a household income below $25k (40% and 35.4%, respectively), were not college educated (59.8% and 57.6%, respectively), and were from the South (22.7% and 18.7%, respectively).

The study found that in comparison to White patients, Black patients were more likely to experience significant delays in seeking general (adjusted odds ratio [aOR], 2.38; 95% CI, 1.90-2.96), specialty (aOR, 1.55; 95% CI, 1.27-1.87), or follow-up (aOR, 2.25; 95% CI, 1.83-2.74) care, as well as experience delays in filling a prescription (aOR, 2.31; 95% CI, 1.99-2.68) due to not being able to afford it.

“Our data showing the disproportionate effect of the prescription cost barrier on Black and Hispanic patients with CISDs may mean these patient populations could have worse outcomes compared to other racial and ethnic groups. This is especially important given the introduction of highly effective but costly therapies for CISDs,” the researchers said.

Black patients were also more likely to be affected by structural barriers including delays to care due to transportation issues (aOR, 3.27; 95% CI, 2.72-3.92), not being able to take time off from work (aOR, 1.23; 95% CI, 1.02-1.49), needing to provide child care (aOR, 1.67; 95% CI, 1.18-2.31), needing to provide adult care (aOR, 1.73; 95% CI, 1.13-2.56), and living in a rural area too far away from a health care provider (aOR, 1.67; 95% CI, 1.22-2.26).

Similar findings were found in Hispanic patients in both the cost and structural barrier data sets.

Beyond structural barriers, Asian, Black, and Hispanic patients were more likely to report having never seen a health care provider with a similar ethnic or cultural background (ie, race, religion, native language) as them.

Asian, Black, and Hispanic patients were also significantly more likely to experience delays in seeking care at least some of the time, because they could not find a health care provider sharing a similar background.

“Prior work has found that patient-provider race concordance can improve patient experience and medication adherence. Increasing the diversity of the workforce in dermatology and other specialties is critical, particularly in light of our data suggesting that increasing diversity of providers may lead to a reduction in delays in seeking medical care,” the researchers said.

The researchers acknowledge that participants in All of Us may not be representative of all US adults. Additionally, the sample of patients in this study had a heterogeneous set of CISDs.

The study was also limited in not knowing whether patients experienced barriers in seeking care for CISDs and related comorbidities, or for other unrelated conditions. The extent in which patients experienced these barriers was also unknown.

To improve equal access to health care for patients with CISDs, the researchers of this study suggest future research to address and identify affordability strategies, reduce structural barriers to care, and increase diversity in the health care workforce.

“In addition, given our analyses suggesting that socioeconomic inequities may underpin racial and ethnic disparities in the barriers to care among patients with CISDs, broader advocacy efforts by dermatologists and other providers are also needed to address structural racism and systemic issues contributing to healthcare disparities among historically marginalized populations,” the researchers concluded.


Nock MR, Barbieri JS, Krueger LD, Cohen JM. Racial and ethnic differences in barriers to care among us adults with chronic inflammatory skin diseases: a cross-sectional study of the All of Us Research Program. JAAD. Published online October 12, 2022. doi:10.1016/j.jaad.2022.09.054

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