Health Insurance Coverage as a Social Determinant of Osteoporosis Diagnosis in a Population-Based Cohort Study of Older American Adults

Abstract

Social determinants of health theoretical frameworks identify health insurance coverage as a determinant of older adults’ osteoporosis diagnoses, which results in health inequities. In this research, we used the longitudinal Health and Retirement Study dataset of older United States adults, sampled biennially from 2012 to 2016. Logistic regressions estimated odds of osteoporosis diagnosis with and without a bone scan and/or hip fracture, holding insurance type, and health and demographic factors constant. Results were validated using the National Health and Nutrition Examination Survey. Probable underdiagnosing is present in older adults identifying as Black/African American and as males without a bone scan, regardless of fracture status, potentially as products of structural racism and sexism. Models including a bone scan show a reduction in disparities. These findings suggest having a bone scan is still crucial for addressing health inequities in older adults, and remedying barriers to accessing a scan is paramount.

Structural Inequity and Socioeconomic Status Link to Osteoporosis Diagnosis in a Population-Based Cohort of Middle-Older-Age Americans

“…For example, in 2 models, identifying as Black/African American is linked to lower odds of osteoporosis diagnosis. In Model 2 this is likely attributable to the exclusion of the bone density scan variable, which previous research has shown eliminates the racial/ethnic disparity in diagnosis 13 and was purposely added to show this phenomenon. However, this result also shows up in Model 6, which includes the bone density scan variable.…”

“…As described in the theoretical background and depicted in the upper pathway of Figure 1 , allostatic load and other health-related factors may be influenced by exposure to structural and systemic inequalities. As osteoporosis diagnoses are tied to systemic/structural racism, and accessing a bone density scan tempers that effect, 13 we use a variable for whether the individual has had a bone density scan (binary; 0 = no, 1 = yes).…”

“… Conceptual model derived from Barr, 4 Kubzansky et al, 5 Riancho and Brennan-Olsen, 7 Gough Courtney et al, 14 Godde et al, 13 and Phelan et al. 9 WEIRD = Western, educated, industrialized, rich, and democratic societies.…”

“…Yet, while access to scans improved, SES can still result in disparities related to osteoporosis, such as through access to treatment, ability to see specialists, and related issues. 12 - 14 The fundamental cause framework differs from the first potential pathway as it suggests SES will affect health outcomes, regardless of whether it results in chronic stress, in large part because flexible resources (lower right in Figure 1 ) provide important advantages for health.…”

“….a constellation of macro-level systems, social forces, institutions, ideologies, and interactive processes that generate and reinforce inequities among racial and ethnic groups.” Evidence of the role of structural and systemic racism in health has expanded considerably in recent years, and specifically in osteoporosis diagnosis and care (see discussion in Godde et al.) 13 Systemic discrimination is one mechanism through which structural racism plays out, with policies that advantage those in the majority group (ie, people identifying as Non-Hispanic White in the United States) to the detriment of other racial and ethnic groups. 15 , 16 Systemic and structural discrimination constrain access to the flexible resources described by Phelan and Link (eg, socioeconomic resources), 1 , 9 and contribute to health inequities by limiting opportunities and constraining life chances.…”