Academic journal article International Public Health Journal

Adverse Childhood Experiences and Inequities in Adult Health Care Access

Academic journal article International Public Health Journal

Adverse Childhood Experiences and Inequities in Adult Health Care Access

Article excerpt


The relationship between ACEs and measures of health care access, health literacy, health insurance status and gaps in coverage, regular medical care, and medical debt were examined in a sample of patients from primary care settings. Findings replicated previous research documenting the strong connections between childhood adversity and adult health. Individuals who experience more ACEs were more likely to experience challenges in accessing health care in adulthood. Those with higher ACEs scores were significantly more likely than those with lower ACE scores to experience medical debt, were less likely to be insured, were more likely to experience gaps in their health care coverage, and have lower levels of health literacy. Further, those with higher ACE scores were significantly more likely to go without medical care due to financial reasons, seek care in emergency rooms, and less likely to receive consistent care from a primary care doctor than those with lower ACE scores.

Implications of these findings will assist with identifying patients within primary care settings who are likely to experience interruptions in care and struggle significantly with access to care. In addition, results indicate that those with higher ACE scores would likely benefit from enhanced and specialized literacy interventions.

Adverse childhood experiences and health and social inequities

A robust and growing body of research links childhood adversity with poor physical and mental health outcomes. Adverse Childhood Experiences (ACEs) is a term used to collectively describe several key categories of childhood dysfunction including physical, emotional, or sexual trauma, neglect, and various types of household dysfunction such as witnessing violence toward the mother, parental separation or divorce, and household members with substance abuse issues, mental illness, or incarceration.

Fellitti's pioneering work gathered and analyzed data from a large study of insured adults and documented an association between ACEs, risky health behaviors, and the presence of numerous health conditions (1). These findings have been consistently replicated in numerous populations and locales (2, 3). Childhood adversity has been linked to chronic health conditions such as hypertension (4) and obesity (5). Biomarkers of stress and inflammation have been documented (6-8). ACEs can deduct up to two years off the survivor's life expectancy (9).

In addition to physiological research, focus on the long-term health outcomes of childhood adversity have included social determinants of health such as poverty, unemployment, educational attainment, and material hardship (10-12). However, there is little current documentation in the literature regarding the relationship between underserved populations' exposure to ACEs and the critical role of health care accessibility. A Wisconsin study using Behavioral Risk Factor Surveillance System data found individuals with higher ACE scores experienced increased barriers to health care accessibility, were less likely to have health insurance, and were more likely to be enrolled in Medicaid (13). Although scantly confirmed in existing literature, decreasing barriers to health care access is suggested as a preventative measure for underserved populations' exposure to childhood adversity (14).

While there is currently a paucity of published research linking ACEs and health care access, there is convergent evidence from the closely related literature on child maltreatment chiefly focused on the various forms of abuse and neglect. Both cumulative and individual effects of child maltreatment have been associated with health care access. Adults who experienced multiple types of maltreatment in childhood are three times more likely to be unemployed, to experience job loss, to live in poverty, and to become reliant upon on public health coverage, and are less likely to have healthcare coverage (12). …

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