Impact of Limited Access to Surgical Care in Medically Underserved Communities

Abstract

Summary/Background

Medically underserved communities and ethnic minorities constitute a significant portion of the vulnerable population within the United States. Recent changes in the health care structure, rising inflation with a decline in median household income, and the SARS-CoV-2 pandemic have disproportionately impacted communities of low socioeconomic status. Healthcare providers and federal organizations must be aware of how these factors influence access to surgical care to tailor treatment, interventions, and policies better to meet the needs of these populations.

Method

We systematically reviewed 19 articles to identify key factors influencing barriers to health care for minority populations and how the dynamic changes in healthcare structures can further exacerbate this divide.

Discussion

Medically underserved populations face significant barriers to health care due to socioeconomic factors like income, housing instability, and lack of insurance. These areas often have shortages of primary care providers, access to healthy foods, and high-value health care that may lead to unfavorable outcomes. Poor access and utilization of health services can also affect hospital systems, leading to decreased funding and increased hospital closures. Despite federal intervention and policy changes, the need for further support for rural healthcare institutions and underserved populations remains, requiring financial assistance, resource allocation improvements, and incentives for healthcare providers and investors.

Conclusion

Healthcare systems can work towards bridging the gap in access to surgical services by implementing targeted outreach programs and ensuring equitable resource distribution. Additionally, fostering partnerships with community organizations can enhance awareness and address specific barriers these populations face.

Introduction

Medically underserved populations are communities with limited or lacking access to health services. Individuals in these areas often face significant barriers to health care, with socioeconomic factors such as income, housing instability, lack of insurance, and immigration status playing key roles in shaping their healthcare experiences and access. These populations may encounter challenges in obtaining preventive care, timely medical attention, and specialty services, often leading to poorer health outcomes. The US. Health Resources and Services Administration (HRSA) officially designates medically underserved areas and populations based on specific criteria, including a shortage of primary care providers, high infant mortality rates, high poverty levels, or a large elderly population. These designations help guide efforts to target resources and improve healthcare access for those most in need. ¹

Social Determinants of Health-Transportation and Geographical Isolation

Since 2005, the number of hospitals with American College of Surgeons-approved cancer programs has increased. However, the proportion of people living over an hour from these programs has nearly doubled. ² Musaab Munir et al. found that patients residing in the least privileged areas traveled an additional 25 to 50 miles and 10 to 25 minutes longer to undergo high-risk cancer surgery. They were also less likely to undergo a high-risk cancer operation for a range of cancers, including esophageal, lung, pancreatic, or rectal cancer, at a high-volume hospital. This was partly due to the centralization of complex oncologic surgical care into specialized centers and patients being more likely to bypass their nearest high-volume hospitals to reach such facilities to realize improved outcomes. This may paradoxically delay appropriate cancer treatment and even result in worse cancer outcomes.

An analysis in trauma care revealed that a one-minute increase in the estimated ground travel time raises the probability of firearm-related fatalities by 23%. ³ It has also been established that care at high-volume hospitals was associated with fewer complications (>5% decrease) and lower in-hospital mortality (1.1% vs 2.3%) among all patients. However, low-income, racial, and ethnic minority patients are more likely to receive surgical care in low-volume, low-quality hospitals. ⁴ Conversely, underprivileged urbanized patients may experience other factors, such as additional costs at high-volume hospitals and transportation barriers not geospatial in nature, such as a lack of options for public transport.

Health Outcomes in Medically Underserved Communities

Racial and ethnic minorities, including black patients, tend to receive surgery at lower quality, underperforming health centers with limited resources. ⁵ When investigating population-level and within-hospital disparities in surgical care, de Jager et al. found significant disparities in outcomes for patients living in the most deprived areas compared to those in the least deprived areas. Some hospitals in these areas found higher odds of adverse events, including higher readmission, SSI, overall mortality rate, and colectomy-associated mortality. In addition, Black patients also had overall higher odds of adverse outcomes, including readmission and spine complications, compared to whites. ⁴

In addition, in patients with breast cancer, for example, racial and ethnic minority groups were found to have a longer time from diagnosis to surgery compared with whites. As a result, interventions that increased the prevalence of insured populations, such as the expansion of Medicaid, decreased the disparity among the Medicaid/uninsured subgroup in time from diagnosis to surgery, which was not observed among non-expansion states. This also led to an increased likelihood of presenting with early-stage disease, undergoing lumpectomy, and seeking care in academic facilities, particularly among Black patients. ⁶ Nguyen et al. reported similar improvements in time to initiation of treatment within 30 days among minority patients with breast, colon, lung, and prostate cancer in Medicaid expansion states. ² It should be noted, however, that the rate of delayed surgery among White patients increased from 5.8% to 6.2% post-expansion of Medicaid, which denotes a less than absolute improvement in health care disparities leading to unfavorable outcomes.

Higher Rates of Chronic Diseases and Complications

The obesity epidemic in the US, particularly in urban, lower socioeconomic status neighborhoods, primarily affects Black, Indigenous, and people of color adults. Notably, cultural eating habits among non-Hispanic Black adults have been documented as more high-fat, high-sodium, and high-sugar diets, which are a significant factor in chronic disease morbidity and mortality. Prevailing theories include the difficulty of small business grocery stores competing with popular chain grocery stores, the failure of chain grocery stores to invest in underserved neighborhoods, and increases in fast food restaurants or US dollar stores with low-ticket items in these neighborhoods ⁷

Increased Healthcare Costs

Previous literature has established that financial penalties predominantly target hospitals serving communities with low socioeconomic status. Patients in distressed communities were more likely to be readmitted at rates proportional to the distressed community index. They were also 4 times more likely to require medical readmission compared to resource-rich communities. This poses potential issues for hospital reimbursements as the Centers for Medicare and Medicaid penalize hospitals for 90-day readmissions. This also places an added burden on hospitals electing to participate in bundled payment models. Patients in distressed communities were also less likely to be discharged home, leading to an increased demand for nursing facilities while underutilizing postoperative resources, including office visits, telephone calls, or prescriptions. ⁸

Consequences for Public Health

Low-income, racial, and ethnic minority patients are more likely to access healthcare systems, institutions, and primary care providers with limited resources. The lack of access to high-quality primary care providers contributes to a relative lack of specialty referrals, a key step in accessing surgical care. ⁴ Resource-constrained health systems also often lack preoperative clinics while treating a disproportionately higher number of vulnerable and underserved patients. ⁹ This is further compounded by the fact that procedure requests have declined disproportionately post-SARS-CoV-2 pandemic for non-English speaking patients, those without insurance, and those who live farthest from care, as reported by Joseph A. Lin et al. ¹⁰ Therefore, minority patients may experience more delays in care, poorer risk assessment, and less medical optimization before surgery.

For example, non-English-speaking patients are 78% more likely not to have advance care plans. Similarly, an NSQIP-based study found that white children are 3 times more likely to have a do-not-resuscitate order than Black children despite being at a higher risk and more prone to postoperative complications. Furthermore, differences in advance care planning may also reflect a lack of trust and communication between clinicians and under-represented populations. ⁹

Strain on Health Services

Significant racial and ethnic disparities related to the exposure risk, susceptibility, complications, and access to health care related to SARS-CoV-2 infection have been documented. This was noted explicitly among minorities (including Black, Hispanic, Native American, Alaska Native, and Asian/Pacific Islanders) compared to white non-Hispanic populations. Lower socioeconomic status and reduced ability to socially distance increased the odds of SARS-CoV-2 seroconversion by 64% and hospitalization by 70%. When a susceptible group faces challenges in accessing care, the odds of hospitalization increase by up to 135%. ¹¹ Consequently, ethnic minorities suffer increased infection rates, complications, and mortality compared to non-Hispanic white populations. This disparity persisted even post-pandemic, where decreases in case requests were seen for non-English-speaking patients, the uninsured, and those who were living farthest from care. Patients with lower acuity are also more likely to postpone scheduled procedures, which may ultimately lead to case cancellations. ¹⁰

Another impactful public health phenomenon is the association between food swamps (areas with access to mostly proinflammatory/fast foods) and obesity-related diseases such as early-onset colorectal cancer (EOCRC). Food swamps are known to be a more significant predictor of obesity than residing in a food desert alone. One study used the food swamps score metric, which is the ratio of fast-food and convenience stores to grocery stores and farmers’ markets, to categorize these areas, with higher scores indicating patients living in areas with poorer access to healthy foods. Researchers found that, despite screening advancements, non-Hispanic Black patients, whether they reside in areas with low or high food swamp scores, have a 38–44% increased risk of dying from EOCRC compared to non-Hispanic White patients residing in low-level food swamp score areas. Hispanic patients living in moderate-level food swamp areas also had a 39% increased risk of death due to EOCRC. ⁷

Strategies to Improve Access to Surgical Care

One valuable step toward improving access to surgical care is addressing the trend of hospital and clinic closures. Since 2010, the United States has seen the closure of approximately 130 rural hospitals. ¹² These closures have profoundly affected access to care, creating additional barriers for patients facing challenges such as limited transportation options, longer travel distances, and increased healthcare costs. This issue was further exacerbated by the COVID-19 pandemic, which severely strained rural healthcare facilities and left many rural communities with even more limited access to essential medical services—a situation from which they are still recovering.

The consequences of rural hospital closures extend beyond inconvenience; they directly impact health outcomes. When hospitals close, patients are forced to travel longer distances to receive care, which can delay diagnosis and treatment, especially for time-sensitive conditions. Additionally, receiving hospitals face increased patient volumes, which can alter the quality and efficiency of care. These pressures can lead to overburdened facilities, healthcare provider burnout, and potentially compromised patient care standards. ¹³

There is a pressing need for government intervention and policy development to mitigate these effects and support rural hospitals and clinics. Policies that provide financial support improve resource allocation, and incentivize healthcare providers to work in rural areas can significantly sustain these vital healthcare institutions. By implementing strategies that directly address the unique challenges of rural healthcare delivery, policymakers can help preserve access to medical and surgical services for underserved communities, ultimately improving population health outcomes in these areas.

In 2010, the Affordable Care Act introduced a 10% bonus for major surgical procedures performed in Health Professional Shortage Areas (HPSAs), known as the HPSA Surgical Incentive Payment (HSIP). This initiative aimed to attract general surgeons to medically underserved areas and expired in 2015. ¹⁴

Research on the impact of HSIP has shown mixed results. A study by Taylor et al15 found that the incentive increased the surgeon workforce in some rural communities, while in other areas, workforce numbers remained unchanged or even declined. Conversely, a 2018 study by Diaz et al5 reported an increase in surgical procedures performed in HPSA hospitals compared to non-HPSA hospitals, suggesting some success in expanding access to surgical care in underserved areas.

Medicaid expansion has significantly benefited access to outpatient surgical care. Expanding Medicaid coverage to low-income adults has improved surgical care access for previously uninsured individuals, reducing financial barriers that often delay treatment. A study by Lin et al ¹⁶ in 2020 showed that Medicaid expansion correlates with increased outpatient surgical visits and earlier presentation for surgical issues, as more patients can seek timely care rather than waiting until conditions worsen. This expansion supports a more sustainable healthcare system by reducing the need for emergency care and complex interventions.

Recognizing ongoing challenges in access to surgical care, the Ensuring Access to General Surgery Act of 2023 was introduced to mandate that the Health Resources and Services Administration (HRSA) evaluate current access programs and identify future strategies for improving general surgery services in shortage areas. The bill was referred to a subcommittee in the House of Representatives but has seen little progress since. ¹⁷

Research demonstrates that physician-patient concordance—when patients and physicians share similar backgrounds or identities—can positively impact patient outcomes. Yet, the field of surgery remains one of the least diverse within medicine. Although there has been a steady increase in women entering surgery, the proportion of surgeons from minority backgrounds remains disproportionately low. In 2023, the Association of American Medical Colleges reported that of the 26426 general surgeons practicing in the U.S., 24.9% were female, 6.6% were Hispanic or Latino, and 5.4% were Black. These numbers contrast with the 2023 U.S. Census data showing the general population as 50.5% female, 19.5% Hispanic or Latino, and 13.7% Black or African American, highlighting a significant gap. ¹⁸

To address these disparities, programs such as Nth Dimensions, institution-specific initiatives for under-represented minorities, and the Diverse Surgeons Initiative are committed to guiding and supporting surgeons and surgical applicants from diverse backgrounds. ¹⁹ These pipeline programs provide mentorship, resources, and opportunities essential to fostering a more inclusive surgical field. Additionally, enhancing incentives and support structures to attract and retain surgeons from varied backgrounds could improve patient outcomes by ensuring that more communities see themselves reflected in their healthcare providers. Expanding diversity in surgery can also help increase access to high-quality surgical care for medically underserved populations, thereby addressing healthcare inequities more broadly.

Conclusion

Medically underserved populations face significant barriers to health care due to socioeconomic factors like income, housing instability, and lack of insurance. These areas inherently experience shortages of primary care providers, access to healthy foods, and high-value health care and often comprise minority and/or vulnerable populations. Across many different healthcare metrics, low-income, racial, and ethnic minority patients are more likely to experience disparate access to healthcare, which has resulted in several unfavorable surgical outcomes. Racial and ethnic minorities, specifically Black and Hispanic patients, tend to receive surgery at lower quality, underperforming health centers with limited resources.

Vulnerable populations also grapple with increased financial constraints and longer trips to access health services, factors that are less consequential to more privileged populations. This is partly due to the relatively recent surge in centralization of specialty health care, high volumes of closure of health care facilities in underserved communities, and the pervasive negative impacts of SARS-CoV-2. This occurs despite an overall increase in the number of hospitals with American College of Surgeons-approved cancer programs, the expansion of Medicaid, and the advent of the Affordable Care Act, all of which have been met with mixed results.

Poor access and utilization of health services also have the potential to affect hospital systems. Institutions may battle with low discharge rates to home, increased demand for skilled nursing facilities, and increases in health care metrics associated with poor quality care, such as readmission and mortality rates. This may eventually lead to decreased institutional funding, increasing hospital closure rates.

However, it cannot be understated that despite recent federal intervention and policy developments, the need to further support rural healthcare institutions and underserved populations by providing financial support, improving resource allocation, and incentivizing healthcare providers and investors in these areas remains.