Care denied: US residents who are unable to obtain needed medical services

Is insurance a more important determinant of healthcare access than perceived health? Evidence from the Women's Health Initiative

Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.

Living on the edge: a phenomenological study of medically uninsured working Americans

An estimated 35 to 50 million Americans have no medical insurance; the vast majority are employed persons and their dependents. This phenomenological study was developed to make visible the experience of working Americans living on the edge-forced to walk a fine line between health and illness without the safety net of medical insurance. A purposive sample of 12 individuals was asked, "What is it like to be working and without medical insurance? Based on textual analysis, using an adaptation of Colazzi's method, themes were grouped into four theme clusters: A Marginalized Life, Up Against Rocks and Hard Places, Making Choices-Chancing It, and Getting By-More or Less. These are illustrated through commentary and direct quotation to depict an overall sense of the experience. Implications for nurses charged with addressing the needs of the medically uninsured and for nursing as a whole are discussed.

Developing a measure of unmet health care needs for a pediatric population

BACKGROUND

Quantified measures of unmet health care needs can be used to evaluate health care interventions, assess the impact of managed care, monitor health status trends in populations, or assess equity of access to medical care across population subgroups. Such a measure needs to be simple, relatively easy to obtain, inexpensive, and appropriately targeted to the population of interest.

OBJECTIVE

To develop a measure of unmet health care needs that is specifically targeted to a pediatric population.

SUBJECTS

Study participants consisted of children, aged 1 to 5 years (n = 1,031), and adolescent mothers, aged 13 to 19 years (n = 172), predominantly from poor, minority families in New York City.

RESEARCH DESIGN

Based on a measure, the symptoms-response ratio, developed for all age groups, this study replicated Taylor's procedures specifically for children and adolescents. Respondents were asked if they had experienced a set of physical symptoms and if they saw a doctor in response. A panel of pediatricians rated the same symptoms as to whether health care should be sought.

RESULTS

The measure achieved adequate inter-rater reliability and good construct validity. The children's overall use of health services did not differ from the pediatric panel's expectations, but with differing degrees of unmet needs by symptom. Adolescents sought care less often than the expert panel members believed they should.

CONCLUSIONS

The symptoms-response ratio provides a good balance of a simple and inexpensive measure while yielding a fair estimate of unmet needs for primary care. This analysis created a pediatric measure targeted to the needs of young children and adolescent females.

Physician-evaluated and self-reported morbidity for predicting disability

OBJECTIVES

This study compared the predictive validity of physician-evaluated morbidity and self-reported morbidity on disability among adults.

METHODS

Subjects from a large national survey (n = 6913) received a detailed medical examination by a physician and were asked about the presence of 36 health conditions at baseline. Disability measured 10 and 15 years later was regressed on the morbidity measures and covariates with tobit models.

RESULTS

Although physician-evaluated morbidity and self-reported morbidity were associated with greater disability, self-reports of chronic nonserious illnesses manifested greater predictive validity. Disability was also higher for obese subjects and those of lower socioeconomic status.

CONCLUSIONS

The findings demonstrate the predictive utility of self-reported morbidity measures on functional disability.

Perceived barriers to prenatal care services

PURPOSE

The purpose of this study was to determine barriers to prenatal care services and to determine if barriers differed by demographic characteristics in a low-income population.

DESIGN

Descriptive correlational study with 110 women who sought prenatal care after the 20th week of gestation.

RESULTS

Two items were major barriers to seeking prenatal care: long waiting times at the time of appointments and the cost of getting care. Significant relationships were found based on the age and race of the women.

CLINICAL IMPLICATIONS

Some identifiable variables prevented these women from seeking early prenatal care; however, the barriers identified are amenable to change. Strategies to reduce barriers could include providing more culturally competent care, more timely appointments, better use of the woman's time when appointments are kept, educating women in the community about the availability of low-cost care, and assistance at prenatal care sites for facilitating completion of insurance and financial applications. Barriers to prenatal care varied by demographic group; therefore, identifying the characteristics of the group being served seems important in efforts to decrease barriers to care.

Prenatal, intrapartum, and newborn care provided by health maintenance organizations: Medicaid versus commercial enrollees

A large majority of states have adopted a policy of enrolling Medicaid and other low-income populations in managed care organizations. Analysts have raised several questions relating to whether these populations will achieve appropriate access and utilization of services, including prenatal, intrapartum, and newborn care. Data from a national survey of health maintenance organizations are used to compare access to these kinds of care for Medicaid and commercial enrollees. Overall, utilization of services by the two populations is comparable.

Trends in perceived cost as a barrier to medical care, 1991-1996

OBJECTIVES

This study examined trends in perceived cost as a barrier to medical care.

METHODS

The Behavioral Risk Factor Surveillance System was used to analyze monthly telephone survey data from 45 states.

RESULTS

Overall, the percentage of persons perceiving cost as a barrier to medical care increased from 1991 until early 1993 and then declined to baseline values in late 1996. Perceived cost was a greater barrier in 1996 than in 1991 for persons with low incomes and for those who were unemployed and uninsured. For self-employed persons, percentages increased until mid-1993 and then remained constant.

CONCLUSIONS

Further efforts are needed to improve access to medical care for socially disadvantaged populations.

Trends in health insurance coverage, 1989-1997

The authors analyze trends in health insurance coverage in the United States from 1989 through 1997, using cross-sectional surveys by the U.S. Census Bureau (Current Population Survey) of 160,000 persons representative of the non-institutionalized population. Between 1989 and 1997, the number of people without health insurance increased by 10.1 million to 43.4 million. From 1989 to 1993, the proportion covered by Medicaid increased by 3.6 percentage points while the proportion covered by private insurance declined by 4.2 percentage points. Since then, private coverage rates have stabilized and Medicaid coverage has decreased. Consequently, the number and percent uninsured continues to rise. Young adults age 18-39 had the largest increase in the proportion uninsured, and rates among children have also risen steeply since 1992. While blacks had the largest increase in the percent uninsured, Hispanics accounted for 35.6 percent of the increase in the number uninsured. Low-income families constituted over half of the increase in the number uninsured, but since 1993 the middle income group had the largest increase in the percent uninsured. Northeastern states had the largest increase in the percent uninsured. Thus, despite economic prosperity, the numbers and rates of the uninsured continue to rise. Principally affected are children and young adults, poor and middle-income families, blacks, and Hispanics.

Managed care organizations and mammography: opportunities to serve underserved women

Breast cancer is one of the major causes of mortality and morbidity among women. Breast cancer screening (mammography) has been shown to be an effective preventive service. Significant proportions of women for whom mammography would be an appropriate intervention, especially older, low-income, and minority women, do not receive it. A large proportion of American women (including those in the workforce or who are Medicare and Medicaid beneficiaries) is now enrolled in managed care plans and that trend is likely to continue. Analysts have identified several concerns related to access and use of preventive services by low-income and other vulnerable populations. Research related to these concerns is summarized. Many research-based interventions have been identified that increase the likelihood of women receiving mammography. These are summarized and recommendations are made for managed care organizations to implement them.

Primary care and addiction treatment: lessons learned from building bridges across traditions

A primary care unit combined with residential addiction treatment allows patients with addictive disease and chronic medical or psychiatric problems to successfully complete the treatment. These are patients who would otherwise fail treatment or fail to be considered candidates for treatment. Health care providers should have a background in primary care and have the potential to respond professionally to clinical problems in behavioral medicine. Ongoing professional training and statistical quality management principles can maintain morale and productivity. Health education is an integral part of primary care. The costs of such concurrent care when viewed in the context of the high societal and economic costs of untreated addictive disease and untreated chronic medical problems are low. The principles used to develop this primary care unit can be used to develop health care units for other underserved populations. These principles include identification of specific health care priorities and continuity of rapport with the target population and with addiction treatment staff.

[Vaccination coverage and risk factors associated to non-vaccination in a urban area of northeastern Brazil, 1994]

INTRODUCTION

The assessment of vaccination coverage and risk factors for non-vaccination is important to evaluate vaccination programs and to identify children not properly vaccinated.

METHODS

A cross-sectional household survey was carried out in the municipality of S. Luís, Maranhão, Brazil by means of a standardized questionnaire. Multistage cluster sampling was used to identify children of 12-59 months of age residing in the city in 1994. The mother or other person responsible for the children was interviewed. Fifty census clusters were visited and 40 households were sampled in each. On average, 15 children were found in each cluster. Design effect was calculated for each estimate. Health service utilization was analyzed according to socioeconomic and demographic indicators, and perceived morbidity using proportional hazard modeling (Cox's regression).

RESULTS

Vaccination coverage levels were 72.4% for BCG, 59.9% for three doses of polio vaccine, 57% for three doses of DTP vaccine and 54.7% for measles vaccine. Vaccination levels have remained statistically unchanged over the last three years. Lower maternal schooling continues to be associated with increased risk of non-vaccination in the multivariable analysis.

CONCLUSION

Vaccination levels were low. Health education activities are one of the suggested strategies to increase vaccination coverage.

The value of health insurance: the access motive

Why do people purchase health insurance? Many economists would answer that it permits purchasers to avoid risk of financial loss. This note suggests that health insurance is also demanded because it represents a mechanism for gaining access to health care that would otherwise be unaffordable. For example, although a US$300,000 procedure is unaffordable to a person with US$50,000 in net worth, access is possible through insurance because the annual premium is only a fraction of the procedure's cost. The value of insurance for coverage of unaffordable care is derived from the value of the medical care that insurance makes accessible.

Monetary and nonmonetary costs to patients attending an ambulatory dermatology clinic

BACKGROUND

Despite universal coverage under a provincial health plan, the residents of Ontario, Canada, still bear some costs for outpatient care, particularly for prescription drugs.

OBJECTIVE

To determine the financial and nonmonetary costs borne by patients presenting at a dermatology clinic in an academic centre, and to assess the extent to which these costs were problematic.

METHODS

Consecutive new patients in a 6-week period completed a self-administered questionnaire.

RESULTS

Eighty-six of 140 questionnaires (61%) were returned for analysis. The mean total cost to patients was C$28.92 (range $0 to $177.00). Medications were the largest expense (mean $35.66 for those receiving medication). Despite relatively prompt referrals (mean 12.4 days) and short in-office waiting time (mean 26.5 minutes), there was a trend for subjects to rate time costs as more problematic than monetary costs.

CONCLUSION

Patients attending a dermatology clinic bear variable monetary and nonmonetary costs. For some patients these costs may have the potential to impair access to care.

Going bare: trends in health insurance coverage, 1989 through 1996

OBJECTIVES

This study analyzed trends in health insurance coverage in the United States from 1989 through 1996.

METHODS

Data from annual cross-sectional surveys by the US Census Bureau were analyzed.

RESULTS

Between 1989 and 1996, the number of uninsured persons increased by 8.3 million (90% confidence interval [CI] = 7.7, 8.9 million). In 1996, 41.7 million (90% CI = 40.9, 42.5 million) lacked insurance. From 1989 to 1993, the proportion with Medicaid increased by 3.6 percentage points (90% CI = 3.1, 4.0), while the proportion with private insurance declined by 4.2 percentage points (90% CI = 3.7, 4.7). From 1993 to 1996 private coverage rates stabilized but did not reverse earlier declines. Consequently, the number uninsured continued to increase. The greatest increase in the population of uninsured [corrected] was among young adults aged 18 to 39 years; rates among children also rose steeply after 1992. While Blacks had the largest percentage increase, Hispanics accounted for 36.4% (90% CI = 32.3%, 40.5%) of the increase in the number uninsured. From 1989 to 1993, the majority of the increase was among poor families. Since then, middle-income families have incurred the largest increase. Northcentral and northeastern states had the largest increases in percent uninsured.

CONCLUSIONS

Despite economic prosperity, the numbers and rates of the uninsured continued to rise. Principally affected were children and young adults, poor and middle income families, blacks, and Hispanics.

Barriers to seeking care following school vision screening in Rochester, Minnesota

School vision screening provides an effective way to identify children who require vision therapy, usually glasses. To benefit from screening, children with abnormal screening test results must receive follow-up eye care, but care may be delayed for months or years. This project used community focus groups in Rochester, Minn., to identify barriers that may delay seeking professional care following school vision screening. Major barriers identified included lack of community awareness about the frequency and potential effect of refractive errors in children, a parental perception of inadequate communication between schools and the parents and community, high cost of corrective lenses, limited availability of convenient eye care appointments, and adolescents reluctance to wear glasses. Program planners developed a community action plan to address the perceived barriers.

The epidemiology of chronic fatigue in San Francisco

Despite considerable research on chronic fatigue syndrome (CFS) and conditions associated with unexplained chronic fatigue (CF), little is known about their prevalence and demographic distribution in the population. The present study describes the epidemiology and characteristics of self-reported CF and related conditions in a diverse urban community. The study used a cross-sectional telephone screening survey of households in San Francisco, followed by interviews with fatigued and nonfatigued residents. Respondents who appeared to meet case definition criteria for CFS, based on self-reported fatigue characteristics, symptoms, and medical history, were classified as CFS-like cases. Subjects who reported idiopathic chronic fatigue (ICF) that did not meet CFS criteria were classified as ICF-like cases. Screening interviews were completed for 8,004 households, providing fatigue and demographic information for 16,970 residents. Unexplained CF was extremely rare among household residents <18 years of age, but was reported by 2% of adult respondents. A total of 33 adults (0.2% of the study population) were classified as CFS-like cases and 259 (1.8%) as ICF-like cases. Neither condition clustered within households. CFS- and ICF-like illnesses were most prevalent among women and persons with annual household incomes below $40,000, and least prevalent among Asians. The prevalence of CFS-like illness was elevated among African Americans, Native Americans, and persons engaged in clerical occupations. Although CFS-like cases were more severely ill than those with ICF-like illness, a similar symptom pattern was observed in both groups. In conclusion, conditions associated with unexplained CF occur in all sociodemographic groups but appear to be most prevalent among women, persons with lower income, and some racial minorities.

Monitoring the consequences of uninsurance: a review of methodologies

The proportion of the United States population without health insurance continues to grow. How will this affect the health of the nation? Prior research suggests that the uninsured are at risk for poor health outcomes. They use fewer medical services and have higher mortality rates than do insured persons. The episodic nature of uninsurance and its prevalence among disadvantaged groups makes it difficult to ascertain the health effects of uninsurance. The goal of this review is to assist researchers and policy makers in choosing methodologies to assess the effects of uninsurance. It provides a compendium of methods that have been used to examine the health consequences of uninsurance, the populations in which these methods have been used, and the strengths and weaknesses of different approaches. The review highlights the need for more longitudinal studies that focus on community-based samples of the uninsured.

Access to dental care in the United States

The authors analyzed data from the 1994 National Access to Care Survey and estimated the extent of dental care wants in the U.S. population and in various population subgroups. The authors found that 8.5 percent of the population wanted, but did not readily obtain, dental care in 1994. The prevalence of unmet dental care wants varied by demographic and socioeconomic characteristics, and income and health insurance status. Findings suggest that financial barriers to access are significant in explaining the prevalence of wanted dental care.

Insurance or a regular physician: which is the most powerful predictor of health care?

OBJECTIVES

This study compared the relative effects on access to health care of relationship with a regular physician and insurance status.

METHODS

The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5 academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year.

RESULTS

After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit [OR] = 4.5%, 95% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician.

CONCLUSIONS

Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care.

The demographic characteristics of Medicaid-eligible uninsured children

OBJECTIVES

This study estimated the number of uninsured children in 1993 who were eligible for Medicaid.

METHODS

Data from the March 1990 and 1994 Current Population Surveys were analyzed.

RESULTS

At least 2.3 million Medicaid-eligible children were uninsured in 1993. These children were more likely to have a working parent than children on Medicaid. Higher proportions of uninsured children less than 6 years of age, children who lived in female-headed single-parent families, and African-American and Hispanic children were eligible for Medicaid.

CONCLUSIONS

Many eligible children do not enroll in Medicaid, and they differ in specific ways from enrolled children.

Health care coverage: traditional and preventive measures and associations with chronic disease risk factors

Physician counseling of patients on health related activities is an essential component of chronic disease prevention, however this requires patients to have ready access to health care providers. Previous studies have explored access to health care in terms of health plans and cost without accounting for the lack of preventive coverage inherent in many insurance policies. This study compares two measures of health care access, one using an assessment of cost and health plan availability, and a new coverage measure including preventive services. Data was collected from 2574 adult respondents to the 1991-92 Missouri Behavioral Risk Factor Surveillance System Surveys. Odds ratios were generated for demographic variables, health related behaviors and preventive screening and the two coverage measures. Using health plan and cost 22% lacked full coverage, however including availability of preventive coverage almost 60% lacked full coverage for preventive care. For both coverage measures significant associations were found with age, exercise, marital status, routine checkup and mammography screening. Using the measure of coverage of preventive services, rural residents and those who had never had cholesterol screening were more likely to lack coverage. Inclusion of preventive care in measures of health care coverage may alter previously reported associations with socio-demographic and health related factors. Policy makers should realize that including preventive services in health care coverage greatly increases the number of individuals lacking adequate coverage, and that those lacking adequate coverage are the least likely to undergo preventive screening.

An examination of racial and ethnic differences within a sample of Hispanic, white (non-Hispanic), and African American Medicaid-eligible pregnant substance abusers. The MOTHERS Project

White (n = 213), African American (n = 210), and Hispanic (n = 104) Medicaid-eligible, chemically-dependent, pregnant women were interviewed during their stay in stay in publicly-funded detoxification centers in Massachusetts. Comparisons of demographic, psychosocial, and substance abuse variables revealed significant intergroup differences in almost all instances. There appears to be as much heterogeneity within the treatment population subgroup of pregnant women as there is across different treatment populations. Ramifications of the observed differences for treatment planning and service provision are discussed.

Hypertension-related morbidity and mortality in the southeastern United States

Stroke mortality is higher in the Southeast compared with other regions of the United States. The prevalence of hypertension is also higher (black men = 35%, black women = 37.7%, white men = 26.5%, white women = 21.5%), and the proportion of patients whose hypertension is being controlled is poor, especially in white and black men. The prevalence of hypertension-related complications other than stroke is also higher in the Southeast. The five states with the highest death rates for congestive heart failure are all in the southern region. Of the 15 states with the highest rates of end-stage renal disease, 10 are in the Southeast. Obesity is very prevalent (24% to 28%) in the Southeast. Although Michigan tops the ranking for all states, 6 of the top 15 states are in the Southeast, as are 7 of the 10 states with the highest reported prevalence regarding no leisure-time physical activity. Similar to other areas of the United States, dietary sodium and saturated fat intake are high in the Southeast; dietary potassium intake appears to be relatively low. Other factors that may be associated with the high prevalence, poor control, and excess morbidity and mortality of hypertension-related complications in the Southeast include misperceptions of the seriousness of the problem, the severity of the hypertension, lack of adequate follow-up, reduced access to health care, the cost of treatment, and possibly, low birth weights. The Consortium of Southeastern Hypertension Control (COSEHC) is a nonprofit organization created in 1992 in response to a compelling need to improve the disproportionate hypertension-related morbidity and mortality throughout this region. The purpose of this position paper is to summarize the data that document the problem, the consequences, and possible causative factors.

Measles vaccination levels of children enrolled in WIC during the 1991 measles epidemic in New York City

OBJECTIVES

This study assessed measles vaccination rates and risk factors for lack of vaccination among preschool children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC) during the 1991 measles epidemic in New York City.

METHODS

Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30, 1991, at six volunteer WIC sites in New York City were surveyed.

RESULTS

Of the 6181 children enrolled in the study, measles immunization status was ascertained for 6074 (98%). Overall measles coverage was 86% (95% confidence interval [CI] = +/- 1%) and at least 90% by 21 months of age (95% CI = +/- 1%). Young age of the child, use of a private provider, and Medicaid as a source of health care payment were risk factors for lack of vaccination (P < .001).

CONCLUSIONS

During the peak of a measles epidemic, measles immunization rates were more than 80% by 24 months of age in a sample of WIC children. The ease of ascertaining immunization status and the size of the total WIC population underscore the importance of WIC immunization initiatives.

Geriatric use of emergency medical services

STUDY OBJECTIVE

To quantify use by geriatric patients of emergency medical services (EMS) compared with that by young adult patients.

METHODS

We conducted a retrospective, consecutive case series over a 6-month period in a suburban, all-paramedic municipal EMS system serving 76,500 residents, of whom approximately 15% are 65 years of age or older and 33% are between 25 and 45 years old. Patient age, the sole entry criterion, was used to distinguish two groups: the young adult group, defined as patients 25 to 45 years old; and the geriatric group, defined as patients 65 years or older.

RESULTS

Of the 2,712 patients whose cases were reviewed during the study period, 1,734 (65%) met the entry criterion. The geriatric group (n=1,043) accounted for 39% of the total call volume, compared with the young adult group (n=690), which accounted for 25% of total call volume. Patients in the young adult group were 7.3 times more likely to have been in a motor vehicle accident, whereas the GP group was 2.6 times more likely to have cardiorespiratory complaints, 1.8 times more likely to have fallen, and 1.7 times more likely to have minor medical problems requiring transportation and more frequently required advanced life support (ALS) care (54% versus 33%) (P<.001 for all comparisons). Scene times for geriatric patients were found to be longer than those for young adults (ALS, P<.001; basic life support [BLS], P<.05). However, costs billed to the patient were greater for young adults for all care rendered (BLS, P<.001; ALS, P<.05).

CONCLUSION

Use by geriatric patients of EMS differed significantly from that by young adults. Geriatric patients used EMS more frequently and required more ALS care than did young adults. Although geriatric patients required longer scene times for EMS care, young adults incurred greater charges for service. These findings, although perhaps system specific, speak to the need for ongoing analysis of EMS health care delivery to better serve a population increasing in age.

Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey

This DataWatch presents findings on Americans' ability to obtain health care. Data from the 1994 National Access to Care Survey sponsored by The Robert Wood Johnson Foundation suggest that earlier studies have underestimated the access problems facing Americans by not asking about supplementary services such as prescription drugs, eyeglasses, dental care, and mental health care or counseling. Using this more inclusive definition of health care needs, we estimate that 16.1 percent of Americans were unable to obtain at least one service they believed they needed. While income is highly correlated with unmet need, most persons reporting access problems are not poor.