A new report by AARP Pennsylvania and Drexel University's College of Nursing and Health Professions highlights how geographic, racial/ethnic and economic factors are combining to restrict access to health care services for many Pennsylvanians, creating disparities that have become more pronounced during the COVID-19 pandemic.

"Disrupting Disparities in Pennsylvania: Retooling for Geographic, Racial and Ethnic Growth" shows that health inequities are most acute among those living in rural and low resourced areas of the state, and among underrepresented populations (particularly Black/African American and Latino), who lack access to health care, experience digital divide and face persistent local healthcare workforce shortages. The study draws on interviews with key stakeholders statewide, a comprehensive literature review and analyses of databases on the health of Pennsylvanians.

"The pandemic is effectively exacerbating inequities for those living in poorer rural and urban areas by limiting their ability to schedule, and get to, COVID-19 vaccine appointments," said Laura N. Gitlin, PhD, dean of Drexel University's College of Nursing and Health Professions. "For years, social conditions that have led to poor health have also combined with limited resources and unequal access to quality care to create significant disparities in underserved areas of Pennsylvania. These disparities persist and have been exacerbated by COVID-19."

The COVID-19 public health crisis has wreaked havoc on older Pennsylvanians, bringing to the forefront the deep disparities that exist in access to health care and internet connectivity. Now, more than ever, there is an urgent need to bring about systemic and structural change to promote and assure equitable solutions for older adults across the Commonwealth."

Bill Johnston-Walsh, AARP Pennsylvania State Director

Pennsylvania demographic trends point toward a significant expansion of the number of older adults living in poverty with poor access to health care. Currently, about 40% of Pennsylvanians are 50 and older, with nearly 19% over the age of 65. Those older adults currently live predominately in rural areas and are white with low household income.

However, by 2040, the Commonwealth will experience exponential growth in the aging population led by the southeastern part of the state, which is the most populous, racially and ethnically diverse region.

"Our research shows that gaps in access to health care and internet will only continue to grow as Pennsylvania's population becomes older and with the increase in number of low-income adults living in the southeastern part of the state," said Rose Ann DiMaria-Ghalili, PhD, associate dean for Interprofessional Research and Development at Drexel University's College of Nursing and Health Professions.

Geography plays a key role in access to health services and COVID-19 vaccines in other ways. The report finds that each of Pennsylvania's 67 counties has at least one "pharmacy desert," such with few to no pharmacies available. With local pharmacies serving as a key component of Pennsylvania's COVID-19 vaccine distribution plan — especially in rural areas of the state — pharmacy deserts directly impact access to vaccines for those at high risk.

The report shows health care costs are also a leading contributor to health inequities. For example, 6% of adults aged 45-64 do not currently have health insurance and 11% report not seeing a doctor because of cost, with the largest percentages coming from counties representing both rural and urban areas of the Commonwealth.

An increased role for telehealth services could represent a significant step toward improving access to quality health care statewide. Unfortunately, the report documents, a digital divide is furthering inequities for those without access to broadband internet and telehealth care. Few Pennsylvania counties are able to support 100% of their population connecting to the internet. In addition, 8% of households in eight counties report no internet access at all.

"Critically, older Pennsylvanians are disproportionately impacted by the digital divide, whether due to lack of access to broadband, internet or smart devices, or due to digital literacy," said Gitlin from Drexel. "The digital divide hampers their ability to access telehealth services and schedule COVID-19 vaccine appointments online."

"During the pandemic many senior centers, adult day services, libraries and other community settings remain closed. This means that older adults, who do not have access to the internet in their homes, remain disconnected," said AARP's Johnston-Walsh. "Without access to the internet, or the know-how to navigate the decentralized system of scheduling a vaccine appointment, older Pennsylvanians are at a disadvantage to protecting themselves from the pandemic."

The report finds additional barriers to accessing health care for many residents, including a significant workforce shortage. An estimated 14% of Pennsylvanians live in a medically underserved area and 22% live in an area that is both medically underserved and designated as having a health professions shortage. Residents of these areas primarily live in rural areas, or are of minority status, poorly educated, live in poverty and have limited access to transportation.

"Not only do we need more health professionals and direct care workers, we need to prepare the health care workforce to be culturally competent and capable of addressing age-related health care issues including preventing and managing chronic conditions and their impact on everyday activities of living and aging in place at home," said Drexel's Gitlin.

"Solutions to help disrupt health disparities impacting the 50-plus population in Pennsylvania are urgently needed," said Angela Foreshaw-Rouse, operations and outreach manager for AARP Pennsylvania. "The time is now to assure that all individuals are able to live long and healthy lives regardless of where they live or their racial/ethnic background."

Highlights of Disrupting Disparities in Pennsylvania: Retooling for Geographic, Racial and Ethnic Growth include:

COVID-19:

• Each of the 67 counties in PA have at least one pharmacy desert (which was defined at census tract level). Pharmacy deserts will lead to vaccination deserts with vaccine rollout, causing greater disparities in those areas.
• Community-based organizations that provide services for older adults report challenges in delivering virtual services during the pandemic, reporting technology as a barrier.
• During the pandemic many senior centers, libraries and other community settings remain closed and older adults who do not have access to the internet in their homes via computer or smartphone remain disconnected.
• In addition to access-related challenges, distrust of the health care system, especially among Black Pennsylvanians, and safety concerns may contribute to COVID-19 vaccination hesitancy.

  Geographic Challenges:

• About 23% of older adults living in rural communities have cognitive difficulties or difficulties with independent living and lack access to community-based services, such as adult day services, personal care homes and low-income housing, supports that are commonplace in urban areas.
• An estimated 14% of Pennsylvanians live in a medically underserved area and 22% live an area that is both medically underserved and designated a health professions shortage area. Residents of these areas primarily live in rural areas, or are of minority status, poorly educated, live in poverty and have limited access to transportation.
• Rural communities currently have roughly half the physicians per capita as non-rural areas. There are also less hospital beds compared to urban areas and several rural counties have no hospitals.

Access to health care:

• In PA, 6% of adults 45-64 years of age report not having health insurance and 11% report not seeing a doctor because of cost. The areas with the highest percentage of adults 45-64 years of age without health care coverage include Pike, Monroe, Susquehanna and Wayne Counties at 13% with Philadelphia at 10%.
• The cost barrier is a critical issue: 18% of those 45-64 living in Lackawanna, Luzerne and Wyoming and Erie County, and 15% of those living in Philadelphia County reported not able to see a doctor in the past year because of cost.
• Lacking broadband is an impediment to delivering telehealth services in rural areas.

Health and digital literacy:

• Some 7% of Pennsylvanians 50+ report difficulty in understanding information from a health care professional, and older adults report a slightly higher rate of not being able to understand written information.
• Individuals 65+ are less likely to use electronic devices to look for health information, communication with their physician, look up test results and track health charges.

Digital divide:

• Only in Bucks, Chester, Delaware and Montgomery Counties can over 95% of the population use or connect to the internet in their household.
• 12% of counties (Cameron, Clearfield, Forest, McKeon, Philadelphia, Sullivan, Union and Warren) have 8% of households with no internet access.
• Smartphones can lessen the internet access divide by enabling individuals to access the internet on their phone.
• During the pandemic, many senior centers, libraries and other community settings remain closed and older adults, who do not have access to the internet in their homes via computer or smartphone, remain disconnected.
• Lack of broadband internet is an impediment to delivering telehealth services in rural areas.

Workforce shortage and competencies:

• Pennsylvania faces a significant workforce shortage in health care professionals including direct care workers, dentists, nurse practitioners, physical therapists, physicians, physician assistants, pharmacists, psychiatrists, registered dietitians, registered nurses, occupational therapists and social workers.
  • An estimated 14% of Pennsylvanians live in a medically underserved area and 22% live an area that is both medically underserved and designated a health professions shortage area.
  • Residents of these areas primarily live in rural areas, or are of minority status, poorly educated, live in poverty and have limited access to transportation.
• The workforce is unprepared to address complex and co-morbid conditions and lack training in the specialty of geriatrics.