Helmsley: Places of Healthcare Receipt Among New Yorkers

Places of Healthcare Receipt Among New Yorkers

Places of Healthcare Receipt Among New Yorkers with High Healthcare Need Over the Course of the Pandemic

Anastasia Koutavas, Mustafa Hussein, Lily Bushman-Copp, Christopher Wimer

July 2026

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 1

INTRODUCTION At the onset of the COVID-19 pandemic, Columbia University, with support from Robin Hood, and T he Leona M. and Harry B. Helmsley Charitable Trust, began collecting data on healthcare access and utilization across New York City via the Poverty Tracker (see text box). The objective was to better understand the healthcare needs of New Yorkers and the difficulties they faced in meeting them. As the pandemic strained healthcare systems nationwide, Poverty Tracker data offered a unique opportunity to understand changes in healthcare access and utilization in New York City. Questions about the pandemic’s lingering effects on healthcare access and utilization continue to be im-portant, especially for vulnerable populations. The Poverty Tracker has attempted to document these changes in healthcare access and utilization. 1 In this brief, we present data on New Yorkers who had high healthcare needs over the course of the COVID-19 pandemic (2021-2022), focusing on the changes in how and where they sought healthcare, their experi-ences making appointments, and their interactions with providers. By charting how these processes have evolved over the pandemic, we can discern why disparities have persisted and help identify pathways to improve healthcare access for all New Yorkers, especially those facing both economic disadvantage and high healthcare needs. Across several indicators tracking places of healthcare receipt, we see that health-care inequities established before the pandemic have started to re-emerge as the height of the pandemic has started to recede.

1 Koutavas, Hussein, Bushman-Copp, and Wimer, “Patterns of Delayed Healthcare Among New Yorkers with High Healthcare Need Over the Course of the Pandemic.”

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 2

KEY FINDINGS In our study period, 2021 to 2022:

g For New Yorkers with high healthcare needs, regular access to a doctor’s office promotes high-value, continuous, and proactive primary care. Utilization of primary care settings such as doctors’ offices and health centers increased in 2022 for more advantaged New Yorkers (93%, up from 86% in 2021) but stayed steady for economically disadvantaged New Yorkers (78% in both years), widening the gap in primary care utilization. g Emergency rooms and urgent care centers also provide patients with timely care for urgent needs, although often at higher costs (both to patients and to healthcare systems). In 2022, economically disadvantaged, high-need New Yorkers continued to rely more on emergency rooms (29%) and urgent care centers (50%) than their more advantaged counterparts (11% and 44%, respectively). g Difficulty finding or making appointments may partially explain the higher rates of urgent care and emergency room usage among the economically disadvantaged. We find that economi- cally disadvantaged New Yorkers were less likely to find it easy to make appointments in 2022 than in 2021 (59% versus 67%, respectively) while more advantaged New Yorkers found it eas- ier to make appointments in 2022 (68%, up from 62% in 2021). This gap in the ability to make healthcare appointments has thus widened as well between less and more advantaged New Yorkers. g Although New Yorkers with high healthcare needs overall have experienced less difficulty getting to their healthcare appointments by 2022, those facing economic disadvantage were more likely to report transportation-related barriers than their more-advantaged counterparts (11% versus 4% in 2022) as a reason for difficulty getting to their appointments. g The propensity to seek healthcare, both overall and in certain settings over others, is informed by prior experiences with patient-provider interactions. Regardless of disadvantage, New Yorkers with high healthcare needs reported more positive clinical interactions with provid- ers in 2022 than in 2021, including that providers were more likely to listen to their concerns (among the economically disadvantaged, 80%, up from 72%; among the more advantaged, 79%, up from 65%). Nonetheless, in 2022, 14% of economically disadvantaged, high health- care-need New Yorkers reported avoiding seeking healthcare in the previous year out of fear of discrimination, unfair judgment, or disrespect, up from 10% in 2021. This was true of only 5% of the more advantaged, down from 7% in 2021.

y s

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 3

Our approach For this report, we follow changes in the healthcare experiences of New Yorkers with high healthcare need (hereafter, “high-need”). We define high need as having multiple chronic health conditions, a work-limiting health condition, or serious psychological distress (see text box). We distinguish between high-need New Yorkers with and without economic disadvantage over two time periods: 2021 and 2022. 2 Economic disad- vantage is defined as being in poverty (as defined by the Supplemental Poverty Measure, or SPM) or expe- riencing material hardship (reporting difficulty meeting basic needs). 3 Our sample contains 705 high-need New Yorkers, 371 (53%) of whom are economically disadvantaged. 4 About the Poverty Tracker Launched in 2012, the Poverty Tracker surveys a representative sample of New Yorkers several times throughout the year, providing critical information on the dynamics of poverty and other forms of disadvantage in the city. Unlike other surveys, the Poverty Tracker explores how New Yorkers experi- ence poverty and material hardship over time, rather than in a single day, month, or year. In addition, the Poverty Tracker focuses on more than income poverty; annually, the study collects data on other core measures of disadvantage, such as material hardships and health problems. We use these al- ternative measures to understand how certain forms of disadvantage, or multiple, overlapping forms of disadvantage, make it harder for New Yorkers to get by. The Poverty Tracker also collects data on other aspects related to New Yorkers’ well-being, from asset and debt accumulation, to social service program utilization, to spending and consumption patterns, in order to form a better under- standing of how New Yorkers are faring within the city.

High healthcare need (high-need)

Two or more of the following self-reported chronic health condi- tions: asthma, diabetes, hypertension, cancer, heart disease

Multiple chronic health conditions

A health problem or disability that prevents one from working or limits the kind or amount of work one can do

Work-limiting health condition

A value of 13 or greater on the Kessler Psychological Distress Scale (K6), which indicates serious psychological distress

Serious psychological distress

2 More specifically, the first time period covers surveys conducted between October 2020 and June 2021. The second time period covers surveys con- ducted between April 2022 and November 2022. 3 For this report we define poverty using the Supplemental Poverty Measure, prior to the subtraction of medical out-of-pocket expenses from resources. For a more detailed definition of poverty and material hardship, see “The state of poverty and disadvantage in New York City: volume 7,” Poverty Tracker Research Group. We exclude medical out-of-pocket expenses so as to not conflate economic need with high healthcare need. 4 For this analysis, we statistically control for basic demographic indicators including race, gender, age, and education level.

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 4

A primer on places of care Healthcare in New York City is similar to healthcare across the United States: People often receive care in community-based physician offices, community health centers (such as federally qualified health centers), or, sometimes, hospital outpatient departments. 5 Access to each of these places of care varies by patient race/ethnicity, ability to pay, insurance status, and neighborhood of residence. 6 For low-income, uninsured, and Medicaid patients, emergency departments have also become a source of non-emergency care, particularly in urban areas. Community health centers play an especially pivotal role in reducing health- care disparities by ensuring access to physical and mental healthcare in communities facing economic disadvantage and barriers to healthcare. 7 Overall, community-based usual sources of care, such as a doctor’s office or a regular primary care provider, promote access to high-value, proactive primary and preventive care. They provide long-term patient-provider relationships, which promote continuity and patient-centeredness, ultimately reducing morbidity and premature mortality and ensuring greater popu- lation health equity. 8 During the COVID-19 pandemic, primary care practices were on the frontlines of test- ing and treatment—even while facing enormous financial strain and operational challenges. Nonetheless, they were resilient, nimble, and innovative, and they recovered as the pandemic started to wane. 9 Findings Where do high-need New Yorkers go to receive healthcare? Doctors’ offices or health centers were the primary place where most high-need New Yorkers regularly received healthcare, regardless of economic disadvantage or period of the pandemic (Figure 1). However, economically disadvantaged New Yorkers were less likely than more advantaged New Yorkers to visit a doctor’s office as their primary place of care, especially in 2022. As the pandemic started to subside, 78% of economically disadvantaged New Yorkers went to a doctor’s office as their primary place of care, similar to 2021. By contrast, 93% of more-advantaged New Yorkers went to a doctor’s office or health center as their primary place of care, up from 86% in 2021. The gap in primary care access between the two groups effec- tively doubled, from 8 to 16 percentage points in 2021 and 2022, respectively. This change suggests that as levels of access among more-advantaged, high-need New Yorkers have recovered, those facing economic disadvantage have continued to experience persistent difficulties in having regular access to a doctor’s office or health center.

5 Green et al., “The ecology of medical care revisited.” 6 Forrest and Whelan, “Primary care safety-net delivery sites in the United States: a comparison of community health centers, hospital outpatient departments, and physicians’ offices.”; Hussein, Diez Roux, and Field, “ Neighborhood socioeconomic status and primary health care: usual points of access and temporal trends in a major U.S. urban area.”; Bliss et al., “Variation in participation in health care settings associated with race and ethnicity.” 7 Pourat et al., “HRSA-funded health centers are an important source of care and reduce unmet needs in primary care services.” Laiteerapong et al., “Health care utilization and receipt of preventative care for patients seen at federally funded health centers compared to other sites of primary care.”; Bruckner et al., “African American/white disparities in psychiatric emergencies among youth following rapid expansion of Federally Qualified Health Centers.” 8 Starfield, Shi and Macinko, “Contribution of primary care to health systems and health.”; Mafi, Wee, Davis and Landon, “Association of primary care practice location and ownership with the provision of low-value care in the United States.”; Pourat et al., “In California, primary care continuity was associated with reduced emergency department use and fewer hospitalizations.”; Doescher, Saver, Fiscella and Franks, “Racial/ethnic inequities in continuity and site of care: location, location, location.” 9 Corlette, Berenson, Wengle, Lucia and Thomas, “Impact of the COVID-19 pandemic on primary care practices.”; Horstman and Lewis, “How primary care is faring two years into the COVID-19 pandemic.”

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 5

Share of high-need New Yorkers using a doctor’s office or health center as their regular place of care Figure 1

While primary care providers can provide a consistent form of healthcare, access to them is no guarantee. “A lot of primary care doctors I didn’t feel really helped me with my needs,” one Poverty Tracker respondent said. “I’d rather go to urgent care for a cold or anything else, for the most part, because of the insurance.”

When the pandemic strained access to doctors’ offices and health centers, the use of telehealth and urgent care centers grew significantly as alternative settings for non-emergency care. Emergency rooms also con- tinued to fill the healthcare void for those without insurance or ability to pay. Figure 2, below, compares rates of telehealth, urgent care, and emergency room use among high-need New Yorkers in the six months prior to being surveyed during the pandemic. Consistent with national trends, telehealth use declined in 2022, regardless of economic disadvantage. While roughly 40% of high-need New Yorkers consulted a physician using telehealth in 2021, less than a third (28% of economically disadvantaged and 30% of more advantaged) did so in 2022, as practices pivot- ed back to more in-person care. 10 In 2022, economically disadvantaged New Yorkers were persistently more likely to visit an urgent care cen- ter than more-advantaged New Yorkers (51% vs 44%, respectively), even though more-advantaged New

10 Shaver, “The state of telehealth before and after the COVID-19 pandemic.”; Lee et al., “Updated national survey trends in telehealth utilization and modality (2021-2022).”

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 6

Yorkers increasingly utilized urgent care centers through the pandemic (from 37% in 2021 to 44% in 2022). These findings likely reflect the growing availability of urgent care centers, whose numbers have doubled over the past decade, 11 as well as their important role as an alternative source of timely, albeit sometimes costly, healthcare for high-need New Yorkers. Emergency room use dropped among more-advantaged, high-need New Yorkers (from 21% to 11%) in 2022, likely because their other usual places of care (e.g., doctors’ offices) returned to more normal availability and possibly because urgent care centers increasingly became a more affordable substitute. On the other hand, economically disadvantaged New Yorkers used emergency rooms fairly consistently in 2021 and 2022 (roughly 30%), continuing to rely on emergency rooms more than their more-advantaged counterparts. In the 6 months prior to being surveyed Use of specific healthcare settings among high-need New Yorkers Figure 2 Figure 2. Use of specific healthcare settings among high-need New Yorkers

2021

2022

100%

90%

80%

70%

60%

50% 51%

50%

44%

40%

38%

37%

40%

31%

30%

29%

28%

30%

21%

20%

11%

10%

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Went to an urgent care center or clinic in a drug/grocery store

Used telehealth for medical advice/care

Went to a hospital emergency room

All in all, as more-advantaged New Yorkers appeared to be returning to pre-pandemic patterns of access, disadvantaged New Yorkers continued to disproportionately rely on reactive care settings, including urgent care centers and emergency rooms for regular access, suggesting that their struggle to secure stable ave- nues for healthcare persisted through the pandemic. Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: Telehealth, urgent care, and emergency room use are not mutually exclusive.

11 Urgent Care Association, “The essential nature of urgent care in the healthcare ecosystem post-COVID-19.”

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 7

Ease of making healthcare appointments For high-need, economically disadvantaged New Yorkers, experiencing difficulty finding or making medi- cal appointments may partially explain their persistently low rates of reliance on doctors’ offices and high rates of reliance on urgent care and emergency rooms. Figure 3 shows the extent to which high-need New Yorkers found it easy to make healthcare appointments. 12 Fewer economically disadvantaged New Yorkers found it easy to make appointments in 2022 than in 2021 (59% in 2022 versus 67% in 2021). A greater pro- portion of more-advantaged New Yorkers, on the other hand, found it easy to make appointments as the pandemic started to wane (68% in 2022 vs 62% in 2021). Seeking care at urgent care centers or emergency rooms on a walk-in basis is often much less burdensome than visiting a doctor’s office or health center, which require making an appointment during regular hours and completing paperwork well in advance. While the circumstances of the pandemic imposed many restrictions on the ability to access healthcare, urgent care centers and emergency rooms remained easier to access, one factor that likely contributed to the higher levels of reliance on these facilities among high-need, economically disadvantaged New Yorkers.

Long wait times to see providers and the limited availability of appointments can be part of the decision of where to receive healthcare. This was echoed by a high-need, Poverty Tracker respondent: “I have an appointment next week that I waited three months for with a female [urogynecologist],” she said. “If I had major issues, I would’ve had to go to the emergency room if I couldn’t wait that out.”

Share of high-need New Yorkers finding it easy making healthcare appointments Figure 3 Figure 3. Share of high-need New Yorkers finding it easy making healthcare appointments

2021

2022

20% 30% 40% 50% 60% 70% 80% 90% 100%

68%

67%

62%

59%

10% 0%

Economic disadvantage

No economic disadvantage

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 8 Source: Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. 12 On the Poverty Tracker survey, New Yorkers are asked how often it is very easy to make healthcare appointments: “always”, “often”, “sometimes”, “rarely”, or “never”. We define it to be easy making appointments if respondents reported it being “always” or “often” easy. Note: On the Poverty Tracker survey, New Yorkers are asked how often it is very easy to make healthcare appointments: always, often, sometimes, rarely, or never. We define it to be easy making appointments if respondents reported it being always or often easy. Note: On the Poverty Tracker survey, New Yorkers are asked how often it is very easy to make healthcare appointments: always, often, sometimes, rarely, or never. We define it to be easy making appointments if respondents reported it being always or often easy. Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition.

There are many other reasons why high-need New Yorkers may find it difficult to make appointments. Be- yond the mere availability of appointments, the ways in which facilities and providers accommodate and accept patients can shape access to healthcare. 13 These dimensions include the extent to which healthcare providers accommodate patients’ irregular schedules, patients’ ability to navigate healthcare interfaces and fill out forms, as well as patients’ sociomedical experiences with providers, whether their health con- cerns are taken seriously or whether they are treated with respect. Regardless of disadvantage, we find that high-need New Yorkers were more able to receive care outside of standard business hours in 2022 than in 2021. 14 Economically disadvantaged New Yorkers saw a 13-percent- age-point increase in receiving care outside of standard business hours (from 20% to 33%) and more-ad- vantaged New Yorkers saw a 12 percentage point increase (from 19% to 31%) (Figure 4). These increases likely reflect the growing capacity of and access to healthcare facilities following the easing of pandemic restrictions, providing more flexibility to accommodate patients’ scheduling needs. However, economically disadvantaged New Yorkers continued to struggle with certain aspects of navigat- ing the medical system. More than half (54%) of economically disadvantaged, high-need New Yorkers re- ported feeling confident filling out medical forms by themselves in 2022—relative to 57% in 2021—whereas more-advantaged New Yorkers felt increasingly confident filling out medical forms by themselves, from 71% in 2021 to 79% in 2022 (Figure 4). 15 Throughout the pandemic, economically disadvantaged New Yorkers were also persistently less likely to be able to change appointments by themselves relative to more-advan- taged New Yorkers (67% versus 77% in 2022, respectively) (Figure 4). 16 Despite some gains in appointment availability after standard hours, patterns around filling forms and changing appointments contribute to the persistent struggles that economically disadvantaged New York- ers face while navigating their healthcare options. Strengthening provider-based supports, such as navi- gation and paperwork assistance and further accommodations for appointments (see Paulette’s story be- low), can be effective in helping high-need, economically disadvantaged New Yorkers meet their healthcare needs.

13 Penchansky and Thomas, “The concept of access: definition and relationship to consumer satisfaction.” 14 On the Poverty Tracker survey, New Yorkers are asked how often they can receive healthcare outside of standard hours (weekends or evenings): “always”, “often”, “sometimes”, “rarely”, or “never”. Those who respond “always” or “often” are defined as often able to receive care outside of standard hours. 15 On the Poverty Tracker survey, New Yorkers are asked how confident they feel filling out medical forms by themselves: “not at all”, “a little bit”, “some- what”, “quite a bit”, or “extremely”. Feeling confident is defined as responding “quite a bit” or “extremely” confident. 16 On the Poverty Tracker survey, New Yorkers are asked how often they are able to make and/or change a healthcare appointment by themselves: “al- ways”, “often”, “sometimes”, “rarely”, or “never”. Those who respond “always” or “often” are defined as often being able to make/change appointments by themselves.

SPECIAL SERIES: HEALTH & HEALTHCARE IN NY 9

Experiences making healthcare appointments among high-need New Yorkers Figure 4 Figure 4. Experiences making healthcare appointments among high-need New Yorkers

2021

2022

100%

90%

79%

80%

75% 77%

71%

67% 67%

70%

57%

60%

54%

50%

40%

33%

31%

30%

20%

19%

20%

10% 0%

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Getting to appointments High-need New Yorkers may face other barriers that impede their ability to receive healthcare. “Accessibil- ity,” or patients’ ability to geographically reach the healthcare they need, is a core dimension of healthcare access. Over the course of the pandemic, high-need New Yorkers experienced less difficulty getting to their health- care appointments, regardless of economic disadvantage (Figure 5). From 2021 to 2022, the share of New Yorkers who found it very or somewhat difficult to get to appointments declined from 25% to 17% among those with economic disadvantage, while difficulty declined from 15% to 11% among the more-advantaged. This decline suggests that barriers presented by the pandemic, such as transit and mobility restrictions, became less prominent as the pandemic started to wane. However, in both time periods, economically dis- advantaged New Yorkers were still more likely overall to report difficulty getting to their healthcare appoint- ments than more-advantaged New Yorkers—and in fact, the share of those who found it very difficult to get to appointments actually grew (Figure 5). Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: On the Poverty Tracker survey, New Yorkers are asked how often they can get healthcare outside of standard hours, or how often they are able to make and/or change a healthcare appointment by themselves: always, often, sometimes, rarely, or never. The above outcomes are defined as those who responded always or often. Similarly, New Yorkers are asked how confident they feel filling out medical forms by themselves: not at all, a little bit, somewhat, quite a bit, or extremely. Feeling confident is defined as those who responded quite a bit or extremely confident. Note: On the Poverty Tracker survey, New Yorkers are asked how often they can get healthcare outside of standard hours, or how often they are able to make and/or change a healthcare appointment by themselves: always, often, sometimes, rarely, or never. The above outcomes are defined as those who responded always or often. Similarly, New Yorkers are asked how confident they feel filling out medical forms by themselves: not at all, a little bit, somewhat, quite a bit, or extremely. Feeling confident is defined as those who responded quite a bit or extremely confident. Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition.

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 10

Share of high-need New Yorkers who found it difficult to get to their most recent health appointment Figure 5 Figure 7. Share of high-need New Yorkers who found it difficult to get to their most recent health appointment

Very difficult

Somewhat difficult

Not difficult

25%

5% 20%

75%

2022

17%

7% 10% 83%

2021

15%

<2%

13%

85%

2022

11%

<1%

10% 89%

2021

20%

40%

60%

80%

100%

Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorker with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. There are many reasons that high-need New Yorkers might experience difficulty getting to their health- care appointments, especially during the pandemic, which restricted transportation options and mobility around the city at large. In 2022, economically disadvantaged, high-need New Yorkers were more likely than the more-advantaged to have difficulty getting to appointments because of pain (6% vs. 1%, respec- tively) and distance/transportation-related reasons (11% versus 4%, respectively) (Figure 6). This might suggest that economically disadvantaged New Yorkers were less likely to be located near providers and faced greater distance and transportation cost barriers in accessing healthcare. More-advantaged New Yorkers, on the other hand, saw an increase in difficulty getting to appointments because of work or child care (6% in 2022, compared to 1% in 2021), which might be related to returning to work following the height of the pandemic. Regardless, all high-need New Yorkers reported less difficulty getting to their appoint- ments for other, non-listed reasons; qualitative data suggests that much of this “other” drop was related to the waning intensity of the pandemic.

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 11

Reasons high-need New Yorkers had difficulty getting to their last healthcare appointment Figure 6 Figure 8. Reasons high-need New Yorkers had difficulty getting to their last healthcare appointment

2021

2022

40%

35%

Among those facing economic disadvantage:

Among those not facing economic disadvantage:

30%

25%

20%

15%

13%

11% 11%

11%

25%

10%

6% 6%

1% 1%

Distance, transportation,

Pain

Other reason

Distance, transportation,

Pain

Other reason

Source: Poverty Tracker longitudinal survey data; cohorts three and four. Universe includes all high-need New Yorkers. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Patient-physician experiences We next explore high-need New Yorkers’ experiences with providers over the course of the pandemic, us- ing the concept of “acceptability.” A key dimension of healthcare access, acceptability captures the extent to which providers’ sociomedical behavior towards patients matches patients’ desires to be treated with respect, heard out, and taken seriously. Acceptability is a major determinant of patients’ trust in the health- care system, their propensity to seek care, and their desire to make appointments in the future. In many cas- es, a lack of acceptability can contribute to the underutilization of healthcare services, shaping preferences for certain places of care over others. 17 We find that, regardless of disadvantage, high-need New Yorkers generally reported more positive experi- ences with healthcare providers in 2022 than they did in 2021. For example, high-need New Yorkers increas- ingly felt that doctors and healthcare professionals listened to their concerns, with about 80% agreeing so in 2022 regardless of economic background (Figure 7). Further, 82% of economically disadvantaged, high- need New Yorkers felt that doctors answered their medical questions, which remained true over the course of the pandemic. More advantaged New Yorkers also increasingly reported feeling this way, from 78% in 2021 to 84% in 2022. In line with these patterns, high-need New Yorkers also increasingly felt that doctors took them and their symptoms seriously. In 2022, 75% of economically disadvantaged New Yorkers felt that healthcare professionals took their symptoms seriously (from 71% in 2021), as did 85% of more-advantaged New Yorkers (from 70% in 2021).

17 Burgess et al., "The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample."

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 12

Patient-physician experiences among high-need New Yorkers Figure 7 Figure 7. Patient-physician experiences among high-need New Yorkers

2021 2022

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

85%

84%

82% 82%

80%

79%

78%

75%

72%

71%

70%

65%

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Economic disadvantage

No economic disadvantage

Answered their medical questions

Took their symptoms

Listened to their concerns

seriously

However, not all feelings toward providers were positive. In survey year 2022, economically disadvantaged New Yorkers were about three times more likely to report that, in the previous year, they did not seek health- care in order to avoid being discriminated against, judged unfairly, or treated with disrespect—14%, versus 5% of more advantaged New Yorkers (Figure 8). This finding represents a rise in perceived discrimination from 2021, where only 10% of economically disadvantaged and 7% of more-advantaged New Yorkers avoid- ed care for this reason. Medical discrimination can come in many forms, such as being based on one’s race/ ethnicity, health status, income level, or preferred language. This rise in discrimination, especially for dis- advantaged New Yorkers, is also consistent with observed spikes in discrimination and delayed care in the middle of the pandemic. 18 Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: On the Poverty Tracker survey, New Yorkers are asked how often doctors/healthcare professionals listen to their concerns, answer questions, or take their symptoms seriously: always, often, sometimes, rarely, or never. The above outcomes are defined as those who responded always or often. Note: On the Poverty Tracker survey, New Yorkers are asked how often they can get healthcare outside of standard hours, or how often they are able to make and/or change a healthcare appointment by themselves: always, often, sometimes, rarely, or never. The above outcomes are defined as those who responded always or often. Similarly, New Yorkers are asked how confident they feel filling out medical forms by themselves: not at all, a little bit, somewhat, quite a bit, or extremely. Feeling confident is defined as those who responded quite a bit or extremely confident. Source:Poverty Tracker longitudinal survey data; cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition.

18 Zhang et al., “Associations between racial discrimination and delayed or forgone care amid the COVID-19 pandemic.” ; Lund and Ayers, “Ever-changing but always constant: ‘waves’ of disability discrimination during the COVID-19 pandemic in the United States.”

PLACES OF HEALTHCARE RECEIPT AMONG NEW YORKERS WITH HIGH HEALTHCARE NEED 13

Figure 6. Share of high-need New Yorkers avoiding care due to healthcare discrimination In the 12 months prior to being surveyed, did you avoid healthcare out of fear of being judged unfairly, treated with disrespect, or discriminated against? Share of high-need New Yorkers avoiding care due to healthcare discrimination Figure 8

2021

2022

40%

30%

20%

14%

10%

Economic disadvantage

No economic disadvantage

Economically disadvantaged New Yorkers were also more likely to report ever being discriminated in the health care system than more-advantaged New Yorkers. In our 2022 data, one in four economically disad- vantaged New Yorkers reported feeling ever discriminated against when seeking medical care (25%), com- pared to one in ten (11%) more-advantaged New Yorkers. These results offer an important explanation for the continued struggles that disadvantaged New Yorkers may face as they navigate the healthcare system. Patient-provider experiences are an important factor in determining where healthcare will be sought, if at all. As the pandemic started to wane, more high-need New Yorkers reported positive clinical interactions, though many economically disadvantaged New Yorkers continued to delay care for reasons related to pro- vider discrimination. Below, we share a story from Paulette, who described her experiences accessing healthcare as a high- need New Yorker, emphasizing the importance of having a reliable healthcare network and trustworthy pa- tient-provider relationships. Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Source: Poverty Tracker longitudinal survey data, cohorts three and four. High-need refers to New Yorkers with high healthcare needs, such as multiple chronic health conditions, serious psychological distress, or a work-limiting health condition. Note: New Yorkers are asked whether in the 12 months prior to being surveyed they avoided healthcare out of fear of being judged unfairly, treated with disrespect, or discriminated against.

THE PLACES AND PEOPLE OF HEALTHCARE: Paulette’s story

Paulette, 72, manages a life-long psychiatric disorder and suffers from chronic obstructive pulmonary disease (COPD). Since taking early retirement, she receives Social Security, a modest pension, and earnings from very part-time work. She keeps her living expenses low, paying just $550 a month for her studio apartment through the Mitchell-Lama affordable housing program: “It’s a wonderful relief not to have to go to two, three jobs in a day, and all different uniforms. It’s a small amount of money I get, certainly compared to what others get. Because I have this affordable apartment, that’s what gives me the privilege of stay- ing here. I couldn’t afford to live in Kansas for what I can live on in New York.”

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Paulette uses a clinic network associated with a hospital for primary care, specialist referrals, and psychiatric treatment, and had high praise for her providers: “The care there [is] perfect for me… I mean that when you have trust in your doctor, when they know who you are, they know you by name—most people find that in a private doctor circumstance. I’m finding it in a clinic circumstance—having been with these doctors for years, not having the weight of the finances.” Most of Paulette’s providers are easily reached by bus, or a reasonable cab fare when she is very ill, so she doesn’t have much interest in telehealth. But in the height of the pandemic, she switched to speaking to her psychiatrist over the phone: “I like not having to go to that clinic, because it is [very] out of the way for me to go that far… You can be in this really tiny elevator [with] people that are angry or seeing things... it [made] me really anxious and depressed to know, ‘Gee, I got to go down there.’” While Medicare and supplemental health insurance cover the majority of her care, Paulette pays $350 several times per year to see a private pulmonologist for her COPD. She is happy to make this sacrifice on her tight budget because it’s the “best care I’ve ever experienced…Because I can afford that, because I do work a little bit, I have the blessing of being able to pay.” When it comes to making appointments, “There can be situations where you have to wait longer to get an appointment. It could take more than a month, certainly, unless it’s an emergency.” When Paulette couldn’t get an appoint- ment with her pulmonologist during a recent emergency, she went to the emergency room, where she received suboptimal care: “I was trying very hard to advocate for myself [but] the doctors weren’t listening to me… I think it’s partly because the doctors are somewhat paranoid, especially in hospitals, about ruling everything out, doing a thorough job. I think it was partly— especially with one doctor—ego… It was his way or the highway.” Even with improved care and practiced self-advocacy, it can be hard to manage complex health care needs alone, which is why Paulette appreciates the help of the clinic’s patient care navigator: “She calls me once a month. She can make appointments for me. Especially if you’re not feeling well. She does all of the navigation. She gets me in for follow-ups… I can’t praise that system enough. Because I know—especially when you’re not feeling well—there’s nothing more disappointing or frustrating than getting stuck on hold, or going back and forth, waiting for information. It just makes it like a freeway in- stead of a crowded street.”

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CONCLUSION As the pandemic started to recede in 2022, high-need New Yorkers’ practices and experiences with the health- care system evolved. Often, these experiences were different for those who were more or less economically ad- vantaged. Relative to their more-advantaged counterparts, economically disadvantaged New Yorkers continued to disproportionately rely more on reactive healthcare settings, such as emergency rooms and urgent care cen- ters, and less on more primary care-oriented doctors’ offices and health centers. Economically disadvantaged New Yorkers also found it increasingly difficult to make healthcare appointments, struggled with filling out forms and changing appointments, and reported transportation-related barriers to getting to appointments. More-ad- vantaged New Yorkers, on the other hand, appeared to return to a more “normal” healthcare experience by taking advantage of emerging urgent care centers, finding it easier to make appointments, and being more likely to regularly seek care at a doctor’s office or health center. Some experiences were more universal; regardless of dis- advantage, high-need New Yorkers relied less on telehealth services, grew more likely to receive care outside of standard business hours than they were at the height of the pandemic, and reported more positive clinical inter- actions with healthcare providers. While these results, among others, suggest that in some ways, the interruptions to healthcare access posed by the pandemic began to soften, experiences of healthcare discrimination worsened among economically disadvantaged, high-need New Yorkers through the pandemic. Taken together with the results from the companion brief, which explores delayed healthcare and affordability challenges over the course of the pandemic among high-need New Yorkers, we find differences in healthcare us- age of New Yorkers by economic disadvantage. In many ways, economically disadvantaged New Yorkers contin- ued to struggle with accessing healthcare as the pandemic began to subside—delaying care at high rates, having difficulty affording care, making appointments, having difficulty with transportation, and avoiding care due to discrimination. More advantaged New Yorkers, on the other hand, experienced more of a return to normalcy, indi- cating that the obstacles that the pandemic had imposed for them began to subside. Issues related to healthcare access are especially critical for high-need New Yorkers; the continued barriers to care we observe warrant action so that access can be improved for those that need it most.

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