We found that Hispanic CKD patients were less well-educated, had lower household incomes, were younger, and had earlier-stage disease when compared with non-Hispanic White patients. Prior research suggests that older age, limited income, and lower education are associated with an increased risk of developing CKD (25). Our findings suggested there might be an association between CKD and lower socioeconomic status that is not attributed to older age among Hispanics. Furthermore, the connection between lower socioeconomic status and unfavorable dialysis outcomes among racially underrepresented groups has been discussed earlier by other researchers (26). Given the disadvantaged socioeconomic status of our Hispanic participants, it is crucial for them to receive adequate healthcare to mitigate the risk of future dialysis complications.
However, our study found that Hispanic CKD patients had limited healthcare access compared to Whites, confirming the presence of kidney care disparities in the U.S. Our unadjusted and adjusted models found that Hispanic CKD patients were less likely to have insurance coverage and have any routine place for health-related visits. Our findings are consistent with the findings of Agrawal and his colleagues, who reported that CKD patients were less likely to be insured (41.1%) than their White counterparts (90.9%). Agrawal et al. analyzed patient participation data from the National Kidney Foundation's health screening program, Kidney Early Evaluation Program (KEEP), from 2000–2010. This program raised significant awareness among high-risk populations. However, our analysis of the post-KEEP NHANES data signifies continuing disparities in kidney care access, indicating a need for similar strategic interventions across the nation (21). In 2010, the ACA was adopted to improve the healthcare access of the underserved U.S. population. While overall insurance coverage increased in the post-ACA period, the uninsured rate among Hispanics remained high (18). In the post-ACA implementation era, healthcare access for Hispanics improved more than non-Hispanic Whites. Hispanics were less likely to forgo physician visits compared to Whites (19). However, in recent years, the ACA's achievements seem to have moderated. Even if patients have insurance coverage, language barriers, mistrust toward the healthcare system, and lack of cultural competencies by healthcare workers detract Hispanic CKD patients from receiving regular care (10, 18, 27). Our findings also align with the findings of a Pew research centers’ report which found that Hispanics were less likely to have a regular healthcare provider. According to their report, more than double the proportion of Hispanics had no regular place for health-related visits when compared to Whites (10, 28). Additionally, research by the Centers for Disease Control and Prevention (CDC) mentioned that Hispanic adults were less likely to have regular healthcare providers than non-Hispanic Whites and Blacks (28, 29). Our final adjusted logistic regression model (model 5) failed to find an association between CKD patients being Hispanics and the outcome variable of having a healthcare visit in the past year. However, other models for these two variables found associations. It seems that the CKD stage had an impact on the relationship between these variables (Table S3). Healthcare utilization of CKD patients increases in the advanced stages of CKD compared to the early stages. In stage-1 and stage-2, CKD often remains asymptomatic, which might be a reason why early-stage CKD patients have a lower tendency to visit health centers (30). Many people remain in the early stages for months or years without symptoms (30). By enhancing healthcare utilization during this phase, individuals would have the opportunity to receive assistance from healthcare professionals early, enabling them to effectively manage CKD and potentially halt its progression. Conversely, advanced staged CKD patients, especially in stage-4 and 5, require frequent hospital visits, dialysis center visits, and specialized medical attention due to their deteriorating health (21). However, previously published literature expressed that Hispanics had limited healthcare utilization behaviors compared to Whites (21, 31). More Hispanic KEEP participants also reported having extremely or moderately difficult healthcare access than non-Hispanic White or Black CKD patients (21).
Multiple intersecting factors may influence healthcare access disparities. Language barriers, acculturations, miscommunications between providers and patients, lack of support, and distinguished cultural values inevitably affect Hispanics’ access to the formal care system (11, 32). While seeking health, many Hispanic CKD patients prefer religious, spiritual, and cultural remedies over western medical care (33). Additionally, staying in the U.S. as undocumented immigrants, especially for many Hispanics with CKD, makes them ineligible for Medicare or many other insurances, which decreases their likelihood of receiving any systematic care before dialysis and late diagnosis of CKD (34). The delayed identification of CKD exacerbates the need for costly emergency dialysis, placing a significant economic strain on the nation (11). Undocumented immigrants even lack adequate coverage for Medicaid and kidney transplantation. Notably, individuals more than 65 years old and patients with CKD and dialysis are largely covered by Medicare in the U.S (35). Medicare covers around 80% of the dialysis expenses and cost of some medications after kidney transplantation and generally starts covering from the fourth month of dialysis initiation (the first month in terms of home dialysis)(36, 37). Even if individuals have Medicare or other insurance, they might be in high need of supplemental plans to cover doctors’ visits, medications, diagnostic tests, nutritional counseling, and other supportive services, which many Hispanic individuals may lack accepting (36, 38). Patient Protection and ACA expanded private insurance marketplaces, enhancing enrollment periods, and offering affordable coverage to patients with preexisting conditions. ACA’s Medicaid expansion in many states enabled many low-income individuals, including those with Hispanic CKD or dialysis patients, to have insurance coverage and ensure better care access. However, Hispanic CKD patients in non-expanding states are still ineligible for Medicaid or subsidies, limiting their healthcare access (37). The passage of ACA and the expansion of Medicare also improved healthcare utilization and preemptive listings for transplantation for people with color (15, 19). Later, several policies were undertaken to focus on improving kidney care access, yet many of them lacked bringing light on racial equity. In 2019, The Advancing American Kidney Health (AAKH) initiative was introduced with the aspiration of transforming kidney care nationwide. However, the AAKH initiative did not explicitly address health equity concerns. Recently an executive order was announced on Advancing Racial Equity and is hoped to promote kidney health and healthcare equity for historically underserved populations in the long run (39). Future research is needed to understand how these recent policies have influenced the existing racial disparities in kidney care. We recommend more institutional-level, community-level, and policy-level interventions like developing culturally competent workforces, involving community health workers, and allocating more funding in equity research to promote awareness, improve care delivery, and reduce healthcare access disparities in the realm of kidney space (40).
This study offered valuable insights into existing healthcare disparities experienced by Hispanic CKD patients in the post-ACA period compared to Whites. Following Aday & Andersen’s (1975) definition of healthcare access, we selected variables that define both actual and potential entries of individuals into healthcare (41). Among all our response variables, healthcare visits in the past one year described CKD patients' actual entries of healthcare, whereas insurance status and having any routine place for healthcare explained patients' potential entry into healthcare. This study’s findings should be interpreted considering a few limitations. Most study variables were obtained through a self-reported questionnaire. NHANES participants might struggle to accurately recall past experiences or events, leading to a collection of partial information (22). Additionally, cross-sectional analysis cannot ensure causality as well. NHANES uses limited instruments to measure healthcare access. Therefore, many perspectives to measure healthcare access, such as providers' and specialized care availabilities, geographical and transportation accessibilities, cultural, social, and language barriers, and discrimination and biases in the system, have yet to be explored. Future studies are needed to delve into these aspects to better measure healthcare access among Hispanic CKD patients.