Section 2: The Challenge Defined

Understanding the need for community care.

Published Oct 28, 2024

Download Documents

In This Resource:

TABLE 2.1 Barriers to Accessing Veterinary Care
BOX 2.1 Principles of Health Equity

Guidelines Menu

Top 3 Takeaways

Historically, the veterinary profession has best served the economically and socially privileged, leaving marginalized populations most likely to experience barriers in accessing veterinary care.
Systematically addressing access-to-care issues may alleviate some of the moral distress veterinary practitioners currently experience when they are unable to provide care for clients with financial and/or other limitations.
A community care model makes providing access to care for those facing barriers the goal for the veterinary profession.

The Challenge of Access to Care

Over the last decade, the issue of equitable access to veterinary care gained prominence.¹^,²^,³ With approximately two out of three US households now choosing to share their lives with companion animals, US society welcomes pets as a feature of family life.⁴ A profession that encourages animal companionship and asks clients to treat their pets as family members also generates an obligation to make accessible services available to all who need them.
Yet many families find veterinary care inaccessible. The existing model that dominates the marketplace involves clients paying out of pocket and in full for veterinary care at the time of service. Although the pet insurance industry is growing and alternative payment strategies are increasing in availability and use,⁵^,⁶ these options are still beyond the reach of many potential clients. Economic indicators now classify a growing number of Americans as “financially fragile” (see Definitions). Pet caregivers in this income category were the most likely to report difficulties in accessing both routine and urgent veterinary care for their pets.⁷ As veterinary care becomes more complicated and advanced, the costs of care also increase, further exacerbating inequities and access-to-care challenges.

At the same time, many in the veterinary profession continue to believe strongly that those without the means to pay for veterinary services should not keep pets. In 2018, the Access to Veterinary Care Coalition published a report that surveyed the opinions of veterinarians regarding pet companionship and access to care. Among the veterinarians surveyed, 94.9% agreed that “All pets deserve some level of veterinary care” and 86.7% agreed that the inability to obtain veterinary care for their pets negatively impacted the mental health and well-being of families. However, when asked if everyone should be able to keep a pet regardless of their circumstances, 59.8% of respondents disagreed, commenting that “pets are not a right,” and people who cannot meet their basic needs should “not be bailed out for their poor decisions” when they decide to keep a pet.⁸ These types of attitudes create barriers that prevent access-to-care solutions from being fully explored, and it is worthwhile for individuals and teams to examine their pre-existing notions and biases about pet care.

Although financial barriers are the most cited reasons that pet caregivers are unable to access veterinary care,17 other barriers exist as well, including the location of veterinary clinics,⁹ language,¹⁰ and recognition of the needs of the pet (Table 2.1).

TABLE 2.1 Barriers to Accessing Veterinary Care

Barrier	Description
Cost	Client is unable to pay for the care that is offered using the financial tools available at the practice.
Housing and Rentals	Many pet caregivers face challenges finding or maintaining rental housing. Pet medical issues (e.g., new urination or defecation issues, barking or other vocalizations, and unusual waking hours) can compound the risk of eviction. In a 2019 survey of 1,299 pet-owning renters, 72% reported difficulty finding pet-friendly housing, with low-income owners struggling the most.
Veterinary Deserts	The community exists within a “veterinary desert” (rural or urban region with low access to veterinary care), necessitating travel over long distances to acquire care.
Transportation	There may be little or no public transportation to get to the clinic for care and follow-up. Pets may not be allowed on many types of public transportation. In a 2019 study by The Street Dog Coalition, only 3 of the 50 biggest US cities allowed all well-behaved pets to ride public transportation, 10 did not allow any pets to ride (except service animals), and the other 37 only allowed small pets in carriers that fit under the seat (Geller J. The Street Dog Coalition, unpublished data, 2019). Although major ride-share companies publish policies stating service animals are permitted, whether a driver agrees to transport a pet is up to them. Some ride-share drivers may refuse to transport pets or add surcharges like cleaning fees. Pet-specific transport solutions, like pet taxis and ambulances, can be cost-prohibitive for families.
Language	Families may speak a language different from the one primarily spoken by the veterinary team. Although clinics may remedy this in their own practice, language can be a barrier to the family accessing other services in the community care network.
Access to/Familiarity with Technology	Clinics may require online appointments or communication, but not all households have access to technology.
Disability/Accessible Spaces	The mobility of family members/caregivers and accessibility of practice spaces (ramps, assistance with pet carriers, accommodations for medications [e.g., cannot administer pills]) may affect ability to receive veterinary care.

Download Table 2.1 PDF

Neal SM, Greenberg MJ. Putting access to veterinary care on the map: a veterinary care accessibility index. Front Vet Sci 2022;9:857644.

Pet Inclusive Housing Initiative, Michelson Found Animals, Human Animal Bond Research Institute. 2021 Pet-inclusive Housing Report. Petsandhousing.org. Available at: https://fapihitemp.wpengine.com/wp-content/uploads/2022/10/PIHI-Sept20-2.pdf. Accessed May 15, 2024.

Lyft. Pet Policy (Non-Service Animals). Lyft.com. Available at: https://help.lyft.com/hc/en-us/all/articles/115013080648. Accessed January 30, 2024.

Uber. Service Animal and Assisted-device Policy. Uber.com. Available at: https://www.uber.com/legal/en/document/?name=service-animalpolicy&country=united-states&lang=en. Accessed January 30, 2024.

The inequitable distribution of resources accessible to veterinary clients reflects other longtime and ongoing challenges in US society—in particular, structural racism and oppression of Black, Indigenous, and People of Color (BIPOC) populations, immigrants, refugees, and Lesbian, Gay, Bisexual, Transexual and Trans, Queer and Questioning, Intersex, Asexual and Agender, plus additional identity terms (LGBTQIA+) individuals. Social inequities also impact the human-animal bond and the relationship between the veterinary industry and clients. The veterinary profession is one of the least diverse professions in health care today, with more than 90% of practicing veterinarians identifying as white.¹¹ The availability of BIPOC veterinarians may help not only to increase pet companionship rates in underserved communities¹² but also expand access to care for current pet caregivers. Some families may feel more comfortable receiving care from veterinarians who better understand their background and experiences, and for young people, seeing other BIPOC individuals working as veterinarians and veterinary technicians can encourage them to pursue veterinary medicine as a career. In recent years, various media and educational opportunities have been directed at underserved communities to increase awareness of the professional opportunities available in veterinary medicine. BlendVET (https://www.blend.vet/), Pawsibilities Vet Med (https://pawsibilitiesvetmed.com/), and Black DVM Network (https://www.blackdvmnetwork.com/) are some examples of organizations working to increase the diversity of the veterinary profession and expand access to care for BIPOC populations.

Health equity means that everyone receives a fair and just opportunity to be as healthy as possible, regardless of their race, ethnicity, gender, income, education, social status, or other factors that have historically been linked to discrimination or exclusion (Box 2.1). Health equity is not just about ensuring access to health care services; it is also about creating a society in which all individuals have the resources and opportunities to achieve their full health potential. This necessitates a broad societal effort, encompassing health care, education, economic policy, community engagement, and more.

The veterinary industry holds a unique role in ensuring health equity; unencumbered by the regulatory frameworks that surround human medicine, veterinary teams have considerable latitude to implement policies and procedures to reduce barriers to care if they choose to do so. The profession must view diversity, equity, inclusion, and belonging within the larger context of access to veterinary care. It takes the inclusion of allied professions and a diverse system to achieve health equity for all families with pets.

BOX 2.1 Principles of Health Equity

Fairness: Health equity emphasizes that all individuals should have an equal opportunity to achieve optimal health by removing obstacles such as poverty, discrimination, and their sequelae.
Inclusion: Health equity seeks to include all members of society, regardless of their social or economic status, in decision making about health, including service offerings and delivery.
Addressing Disparities: Health equity recognizes that disparities in health outcomes exist among different population groups. Practitioners make efforts to understand and address the underlying causes of these disparities, such as unequal access to health care services, differences in quality of care, or socioeconomic factors.
Social Determinants of Health: Achieving health equity requires addressing the social determinants of health, including the conditions in which people are born, live, learn, work, play, and age. These conditions affect various health, functioning, and quality-of-life outcomes and risks.
Cultural Competency: Health equity involves understanding and respecting the diverse values, beliefs, and needs of different communities and individuals and incorporating these into health care policies and practices.
Access to Care: Ensuring access to comprehensive, quality health care services for all individuals regardless of their ability to pay is critical to health equity. Achieving health equity requires establishing a system that assists with veterinary care expenses and other barriers (e.g., language, mobility, and transportation).
Community Engagement: Engaging communities in identifying and solving health problems is essential for achieving health equity. Engagement means actively involving those affected by health care decisions in planning, implementing, and evaluating strategies to improve health.
Systemic Change: Achieving health equity may require significant systemic changes to health care, education, public transportation, and economic and other systems, including policy changes at various levels of government to remove barriers to health and ensure that resources are distributed fairly.

Download Box 2.1 PDF

Moral Distress and the Veterinary Profession

Among the many challenges facing our profession today is the dominant practice model that requires out-of-pocket payment for services. Such a model limits veterinary care access to those clients with the financial resources to afford care. It also leaves private practitioners with limited options for those clients who cannot pay immediately. Yet not being able to provide care because of a pet caregiver’s financial or other limitations places private practitioners squarely at odds with their veterinary oath, as well as with their love of and desire to help animals and other personal reasons for pursuing a career in veterinary medicine. This gap often leads to veterinary care teams experiencing moral distress. In a 2018 survey of North American veterinarians, more than 70% reported experiencing moderate to severe distress owing to “obstacles they faced that prevented them from providing appropriate care.”¹³ A 2023 survey of UK veterinarians characterized moral distress as an “everyday experience”¹⁴ brought on by an inability to fulfill their ethical obligations to patients and clients.¹⁵

Traditional approaches to access-to-care issues tend to place the burden on individual clients and private practitioners, rather than acknowledging the critical need for systemic change. When combined with other practice stressors such as staff shortages and high turnover, not being able to provide care for financially distressed clients compounds moral distress and escalates burnout, depression, and decreased job satisfaction.¹⁶ Moreover, these challenges are further compounded by negative community reactions that impact the entire practice team when pets in need get turned away. Practitioners facing these burdens may feel overwhelmed and have less capacity to work with individual clients or find innovative solutions on a broader scale. They may even choose to leave the profession.

Operating within a community care model, rather than a private practitioner dealing with these issues alone, can benefit clients, individual veterinary team members, and the profession by increasing job satisfaction and improving retention.

Inequities and Social Determinants of Health

Current and historical inequities create economically stratified communities that lack equal access to safe and affordable housing, education, and green space, as well as a justice system that disproportionately imprisons BIPOC offenders for minor crimes. These systemic injustices worsened during the COVID-19 pandemic, which had a greater health impact on BIPOC individuals and increased social isolation, thus decreasing the opportunities for people of different socioeconomic groups to interact with each other. Socioeconomic conditions affect many aspects of a person’s quality of life, including life span and incidence of health conditions such as obesity, cancer, and infant and maternal survival. Other social determinants of health include access to education, safe and healthy environments, nutritious foods, clean water, and health care.

Bollyky TJ, Castro E, Aravkin AY, et al. Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis. Lancet 2023;401(10385):1341–60.

Yabe T, Bueno BGB, Dong X, et al. Behavioral changes during the COVID-19 pandemic decreased income diversity of urban encounters. Nat Commun 2023;14(1):2310.

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social determinants of health. Available at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health. Accessed May 8, 2024.

The First Steps Toward a Solution

Although the veterinary industry cannot eliminate racism and systemic injustice on its own, acknowledging and acting upon the responsibility to ensure equitable access to veterinary care represents a significant step forward.

Everyone can benefit from the human-animal bond and deserves to experience it.¹⁷ To deny or limit these benefits for some perpetuates societal inequities. Veterinary teams can be quick to suggest that a client with financial limitations surrender their pet and allow a new owner to care for the pet. The very idea that someone should surrender their pet if they cannot afford veterinary care undermines the value of a pet as a family member and breaks the human-animal bond that the profession values. Private practitioners focused on preserving this bond can evolve their thinking about how access to care is viewed and embrace more creative SOC strategies within a community care model.

The 2024 AAHA Community Care Guidelines for Small Animal Practice are generously supported by CareCredit, Hill’s Pet Nutrition, IDEXX, Merck Animal Health, and Pawlicy Advisor.

Citations

Stull JW, Shelby JA, Bonnett BN, et al. Barriers and next steps to providing a spectrum of effective health care to companion animals. J Am Vet Med Assoc 2018;253(11):1386–9.
Blackwell MJ, Wiltzius AJ, Krebsbach SB, et al. Access to veterinary care: barriers, current practices, and public policy. Published December 17, 2018. Available at: https://trace.tennessee.edu/utk_smalpubs/17. Accessed January 5, 2023.
Brown CR, Garrett LD, Gilles WK, et al. Spectrum of care: more than treatment options. J Am VetMed Assoc 2021;259(7):712–7.
American Pet Products Association. 2021-2022 APPA National Pet Owners Survey, Business/Finance Fact Sheet. Americanpetproducts.org. Available at: https://www.americanpetproducts.org/docs/default-source/
uploadedfiles/npos/21-22-businessandfinance. Accessed September 5, 2023.
Chiu LJV, Li J, Lhermie G, et al. Analysis of the demand for pet insurance among uninsured pet owners in the United States. Vet Rec 2021; 189(1):e243.
Cammisa HJ, Hill S. Payment options: an analysis of 6 years of payment plan data and potential implications for for-profit clinics, non-profit veterinary providers, and funders to access to care initiatives. Front Vet Sci 2022;9: 895532.
King E, Mueller MK, Dowling-Guyer S, et al. Financial fragility and demographic factors predict pet owners’ perceptions of access to veterinary care in the United States. J Am VetMed Assoc 2022;260(14):1–8.
Access to Veterinary Care Coalition. Access to veterinary care: barriers, current practices, and public policy. December 17, 2018. Available at: https://pphe.utk.edu/wp-content/uploads/2020/09/avcc-report.pdf. Accessed January 10, 2024.
Neal SM, Greenberg MJ. Putting access to veterinary care on the map: a veterinary care accessibility index. Front Vet Sci 2022;9:857644.
LaVallee E, Mueller MK, McCobb E. A systematic review of the literature addressing veterinary care for underserved communities. J Appl Anim Welf Sci 2017;20(4):381–94.
U.S. Bureau of Labor Statistics. Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity. BLS.gov. 2020. Available at: https://www.bls.gov/cps/cpsaat11.pdf. Accessed January 10, 2024.
Brown A. About half of U.S. pet owners say their pets are as much a part of their family as a human member. Pew Research Center. July 7, 2023. Available at: https://www.pewresearch.org/short-reads/2023/07/07/ about-half-us-of-pet-owners-say-their-pets-are-as-much-a-part-of-theirfamily- as-a-human member/#:~:text=Who%20is%20most%20likely% 20to,Black%20adults%20are%20pet%20owners. Accessed May 15, 2023.
Moses L, Malowney MJ, Wesley Boyd J. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med 2018;32(6):2115-2122.
Fingland RB, Stone LR, Read EK, et al. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. J Am Vet Med Assoc 2021;259(5):463–70.
Ashall V. Reducing moral stress in veterinary teams? Evaluating the use of ethical discussion groups in charity veterinary hospitals. Animals (Basel) 2023;13(10):1662.
Blackwell MJ, O’Reilly A. Access to veterinary care–a national family crisis and case for One Health. Adv Small Anim Care 2023;4(1):145–57.
American Veterinary Medical Association. Human-animal bond. AVMA.org. Available at: https://www.avma.org/one-health/human-animal-bond. Accessed August 3, 2023.